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Complications in Facial Plastic Surgery Randolph B. Capone Jonathan M. Sykes Thieme

Complications in
Facial Plastic Surgery

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Complications in
Facial Plastic Surgery
Randolph B. Capone, MD, FACS
Director, The Baltimore Center for Facial Plastic Surgery
Assistant Professor of Otolaryngology/Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Jonathan M. Sykes, MD, FACS
Immediate Past President, AAFPRS
Professor of Otolaryngology/Head and Neck Surgery
Director, Facial Plastic and Reconstructive Surgery
University of California–Davis Medical Center
Sacramento, California
Thieme
New York · Stuttgart

Thieme Medical Publishers, Inc.
333 Seventh Ave.
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Compositor: Prairie Papers Inc.
Cover Illustration: Shipwreck (1854) by Ivan K. Aivazovsky. Image courtesy of the State Russian Museum, Saint
Petersburg, Russia, whose collection includes this painting.
Printer: Leo Paper Group
Library of Congress Cataloging-in-Publication Data
Complications in facial plastic surgery / [edited by] Randolph B. Capone, Jonathan M. Sykes.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-60406-026-3 (hardback)
I. Capone, Randolph B. II. Sykes, Jonathan M.
[DNLM: 1. Cosmetic Techniques—adverse eﬀ ects. 2. Face—surgery. 3. Medical Errors—prevention & control.
4. Reconstructive Surgical Procedures—adverse eﬀ ects. WE 705]
617.5’20592—dc23
2011052040
Copyright ©2012 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected by copyright.
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Important note: Medical knowledge is ever-changing. As new research and clinical experience broaden our knowledge,
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of the work herein or changes in medical knowledge, neither the authors, editors, nor publisher, nor any other party who has
been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or
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information contained in this publication is accurate and that changes have not been made in the recommended dose or
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Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or
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Printed in China
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ISBN 978-1-60406-026-3
eISBN 978-1-60406-027-0

Complications are inescapable. This text is therefore dedicated to all who practice plastic surgery of the face,
regardless of experience or expertise. Special emphasis, however, is placed on individuals early in practice
so that they might learn from the adversity of others. While untoward outcomes are experienced as fellows,
residents, and medical students, these doctors will now encounter them singularly as the patient’s surgeon.
Although their preparation has been thorough, they will acquire additional experience in the more challenging,
yet more rewarding, school of experience.
Randolph B. Capone, MD, FACS
Jonathan M. Sykes, MD, FACS

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vii
Contents
Foreword by Wayne F. Larrabee Jr. ...................................................................................................................................... ix
Preface .......................................................................................................................................................................................... x
Contributors .............................................................................................................................................................................. xi
1. Facial Plastic Surgery Complications: An Overview ............................................................................................... 1

Randolph B. Capone
2. Management of the Dissatisﬁ ed Patient ................................................................................................................... 5

Jonathan M. Sykes
3. Complications in the Cosmetic Oﬃ ce Setting ........................................................................................................10

Corey S. Maas
4. Anesthesia Complications in Facial Plastic Surgery .............................................................................................17

John H. Eichhorn and Daniel T. Goulson
5. Complications Involving Locoregional Flap Reconstruction of Facial Defects .............................................29

David A. Sherris and Paul R. Young
6. Challenges in Skin Resurfacing ..................................................................................................................................39

Gary D. Monheit and Randolph B. Capone
7. Complications of Upper Eyelid Blepharoplasty .....................................................................................................49

Tom D. Wang and Andrew A. Winkler
8. Complications of Lower Eyelid Blepharoplasty .....................................................................................................58

Robert A. Goldberg
9. Prevention and Management of Adverse Outcomes in Brow Rejuvenation ..................................................68

Randolph B. Capone
10. Rhinoplasty Complications ........................................................................................................................................78

Jaimie DeRosa, Ryan M. Greene, and Dean M. Toriumi
11. Facelift Complications ..................................................................................................................................................90

Jonathan M. Sykes, Ji-Eon Kim, and Ira D. Papel

Contents
viii
12. Complications with Facial Implantation .................................................................................................................97

Edwin F. Williams III and Srinivasan Krishna
13. Complications of Facial Trauma Repair .................................................................................................................106

Sydney C. Butts and Robert M. Kellman
14. Complications of Facial Reanimation ....................................................................................................................125

Patrick J. Byrne and Christopher R. Cote
15. Surgical Correction of Congenital Anomalies and Associated Complications ............................................132

Sherard Austin Tatum III and Sven-Olrik Streubel
16. Complications in Orthognathic Surgery ...............................................................................................................151

Travis T. Tollefson, Shepherd G. Pryor V, and Nicholas W. Rotas
17. Overcoming Adversities in Hair Restoration ........................................................................................................166

John E. Frank
Index .........................................................................................................................................................................................175

ix
Foreword
Randolph B. Capone and Jonathan M. Sykes have given us
a wise and important book, Complications in Facial Plastic
Surgery. Complications—and especially their prevention—
are far too infrequent a focus in our scientiﬁ c literature.
The importance of preventing complications rose to na-
tional prominence with the publication in 1999 of the
Institute of Medicine (IOM) report, To Err Is Human: Build-
ing a Safer Health Care System. The IOM report stated that
“medical errors can be deﬁ ned as the failure of a planned
action to be completed as intended or the use of a wrong
plan to achieve an aim.” Its strong conclusion that “health
care in the United States is not as safe as it should be—and
can be” became a stimulus for the now widely accepted
quality movement in American medicine.
Dr. Capone’s own ﬁ rst chapter is humanistic and em-
phasizes the unique nature of aesthetic surgery. This
book appropriately expands the usual deﬁ nition of com-
plications as “an unfavorable outcome” to now include
“patient dissatisfaction.” All those who work in the ex-
citing, creative, and sometimes frustrating specialty of
facial plastic surgery recognize that patient satisfaction
is a key outcome measure. Dr. Sykes provides thoughtful
advice in his chapter “Management of the Dissatisﬁ ed
Patient.” Their general recommendation—that surgeons
swiftly acknowledge and address complications —has
become almost universally recognized but is appropri-
ately emphasized here.
This book is well organized, with recognized ex-
perts discussing the major areas of facial plastic sur-
gery. Tables provide a good summary of the cause,
prevention, and treatments of speciﬁ c complications.
Complex subjects such as facial implants are explored
with a thorough review of the data and presented hon-
estly without oversimpliﬁ cation. The pearls of wisdom
in each chapter highlight the authors’ experience and
judgment and provide an easily accessible summary
for each topic. The major topics, from minimally inva-
sive procedures to reconstruction surgery to aesthetic
surgery, will be of interest to all facial plastic surgeons.
Drs. Capone and Sykes are to be congratulated for a
work that will doubtless be widely read and improve
outcomes for our patients. I hope to see many future
editions of this ﬁ ne book.
Wayne F. Larrabee Jr., MD
Clinical Professor
Department of Otolaryngology–
Head and Neck Surgery
University of Washington
Editor in Chief
The Archives of Facial Plastic Surgery
Seattle, Washington

x
Preface
No one yearns to be associated with a complications text,
nor wants notoriety as an expert in adverse outcomes.
Yet complications occur and are a fact of surgical practice.
As the colloquial deﬁ nition goes, an expert is one who is
well versed in failure, and this certainly applies to the art
and practice of surgery. Surgeons often learn more from
the sting of a misstep than the satisfaction of a triumph.
A text that is never far from reach in the resident call
room is a surgical complications book, and the informa-
tion contained within has helped countless surgeons on
the wards, in the operating room, and at weekly mor-
bidity conferences.1 Such books provided motivation, in
part, for the present work.
Facial plastic surgeons perform a surprising breadth
of procedures in a variety of venues, including the oﬃ ce,
the hospital operating room, the outpatient surgical cen-
ter, and in some instances, the commercial medspa. The
editors have attempted, therefore, to include chapters by
seasoned authors that cover all aspects of contemporary
facial plastic surgery. Even so, it is diﬃ cult to successfully
describe the management of all complications in all sce-
narios, and the editors make no claims that this work is by
any means exhaustive. There are undoubtedly numerous
complications that occur but are absent from this text.
Another aspect of this work that should be anticipated
is that statistics on this topic are often signiﬁ cantly lack-
ing in the literature, or if present, are determined from
only a small sample. Therefore, universally accepted in-
cidences for the complications discussed hereafter are
typically unknown. Much of the data is either estimated,
anecdotal, or simply absent. However, physicians in gen-
eral, and surgeons in particular, learn from their indi-
vidual observations. The use of anecdotal experience to
mold knowledge and inﬂ uence decision making is com-
mon practice in medicine. So even though the evidence
in this book often does not rise above the level of the ob-
servations of experts, this knowledge can be used to im-
prove others’ level of care and improve patient outcomes.
Upon completion of training, surgeons cross a stark
divide where one day there is ample supervision, and the
next day there is none. It is hoped that a work of this sort
can serve in some small way as a surrogate supervisor or
companion to help provide guidance. The editors have
tried to create such a text for those who practice plastic
surgery of the face, and are indebted to its contributors.
It is our hope that with continued, careful review of all
outcomes good and bad, such a work will help encourage
open and frank dialogue between all colleagues of plastic
surgery, and especially with our patients.
“Success is going from failure to failure
without losing conﬁ dence.”
—Abraham Lincoln
Reference
1. Eisele DW, Johns ME. Complications in Head & Neck Surgery.
First Edition. Mosby–Year Book, 1993.
Randolph B. Capone, MD, FACS
Jonathan M. Sykes, MD, FACS

xi
Contributors
Sydney C. Butts, MD
Assistant Professor and Chief
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology
SUNY Downstate Medical Center
Brooklyn, New York
Patrick J. Byrne, MD
Director
Division of Facial Plastic and Reconstructive Surgery
Associate Professor
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Randolph B. Capone, MD
Director, The Baltimore Center for Facial Plastic Surgery
Assistant Professor of Otolaryngology/Head and Neck
Surgery
Division of Facial Plastic and Reconstructive Surgery
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Christopher R. Cote, MD
Faces First Cosmetic Surgery
Denver, Colorado
Jaimie DeRosa, MD, MS, FACS
Assistant Professor
Harvard Medical School
Facial Plastic and Reconstructive Surgeon
Department of Otology and Laryngology
Massachusetts Eye and Ear Inﬁ rmary
Boston, Massachusetts
John H. Eichhorn, MD
Professor of Anesthesiology
College of Medicine
Provost’s Distinguished Service Professor
University of Kentucky
Department of Anesthesiology
University of Kentucky Medical Center
Lexington, Kentucky
John E. Frank, MD, FACS
Founder, Anapelli Hair Clinic
Assistant Professor of Clinical Otolaryngology
Columbia University College of Physicians and Surgeons
New York, New York
Robert A. Goldberg, MD
Karen and Frank Dabby Professor of Opthalmology
Chief, Orbital and Ophthalmic Plastic Surgery Division
Director, Orbital Disease Center
Co-Director, Aesthetic Center
Jules Stein Eye Institute
Los Angeles, California
Daniel T. Goulson, MD
Vice President for Medical Aﬀ airs
Our Lady of Bellefonte Hospital
Ashland, Kentucky
Ryan M. Greene, MD, PhD
Voluntary Assistant Professor
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology–Head and Neck Surgery
University of Miami Miller School of Medicine
Miami, Florida
Private Practice
Fort Lauderdale, Florida

Contributors
xii
Robert M. Kellman, MD, FACS
Professor and Chair
Department of Otolaryngology and Communication Sciences
SUNY Upstate Medical University
Syracuse, New York
Ji-Eon Kim
Fellow
Facial Plastic and Reconstructive Surgery
University of California–Davis School of Medicine
Sacramento, California
Srinivasan Krishna, MD, MPH
Director
Facial Plastic and Reconstructive Surgery
Bronx Lebanon Hospital Center
Bronx, New York
Corey S. Maas, MD, FACS
Founder and Director
The Maas Clinic
Associate Clinical Professor
University of California–San Francisco
Director
Facial Plastic Surgery Fellowship Training Program
American Academy of Facial Plastic and Reconstructive
Surgery
San Francisco, California
Gary D. Monheit, MD
Total Skin and Beauty Dermatology Center, P.C.
Associate Clinical Professor
Departments of Dermatology and Ophthalmology
University of Alabama at Birmingham
Birmingham, Alabama
Ira D. Papel, MD
Associate Professor
Division of Facial Plastic Surgery
Department of Otolaryngology–Head and Neck Surgery
The Johns Hopkins University
Baltimore, Maryland
Shepherd G. Pryor V, MD, FACS
Founding Director
Valley Facial Plastic Surgery
Private Practice
Scottsdale, Arizona
Nicholas W. Rotas, DDS
Assistant Clinical Professor
Department of Otolaryngology
University of California–Davis School of Medicine
Sacramento, California
David A. Sherris, MD
Professor and Chairman
Department of Otolaryngology
University at Buﬀ alo
Buﬀ alo, New York
Sven-Olrik Streubel, MD, MBA
Pediatric Otolaryngology and Craniomaxillofacial Surgery
Assistant Professor
Department of Otolaryngology
Children’s Hospital Colorado
University of Colorado School of Medicine
Aurora, Colorado
Jonathan M. Sykes, MD, FACS
Immediate Past President, AAFPRS
Professor of Otolaryngology/Head and Neck Surgery
Director
Facial Plastic and Reconstructive Surgery
University of California–Davis Medical Center
Sacramento, California
Sherard Austin Tatum III, MD, FAAP, FACS
Professor of Otolaryngology
Pediatrics Medical Director
Cleft and Craniofacial Center
SUNY Upstate Medical University
Syracuse, New York
Travis T. Tollefson, MD, MPH, FACS
Associate Professor
Department of Facial Plastic and Reconstructive Surgery/
Cleft and Craniofacial Program/Otolaryngology–Head
and Neck Surgery
University of California–Davis
Sacramento, California
Dean M. Toriumi, MD
Professor
Department of Otolaryngology–Head and Neck Surgery
University of Illinois–Chicago
Chicago, Illinois
Tom D. Wang, MD
Professor
Facial Plastic and Reconstructive Surgery
Oregon Health and Science University
Portland, Oregon
Edwin F. Williams III, MD
Medical Director
Williams Plastic Surgery Specialists
Latham, New York
Clinical Professor of Surgery
Albany Medical College
Albany, New York

Contributors
xiii
Andrew A. Winkler, MD
Assistant Professor
Department of Otolaryngology
University of Colorado School of Medicine
Denver, Colorado
Paul R. Young, MD
Resident
Department of Otolaryngology
University at Buﬀ alo
Buﬀ alo, New York

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While lecturing at the Harvard Medical School in the fall
of 1925, Frances Weld Peabody ﬁ rst made his memora-
ble remark that “the secret of the care of the patient is
in caring for the patient.”1 At the time, there was grow-
ing concern that rapid increases in scientiﬁ c knowledge
and emphasis on the pathophysiology of disease were
consuming the attention of those studying medicine.
Peabody felt the pendulum had swung too far toward
medicine as a science than as an art, and his assertion
that physicians should spend as much time caring for
patients as attempting to understand what ails them
secured Peabody a spot in American medical education
history. Two years later, his remarks were published in
JAMA:
What is spoken of as a ‘clinical picture’ is not just
a photograph of a sick man in bed; it is an impres-
sionistic painting of the patient surrounded by his
home, his work, his relations, his friends, his joys,
sorrows, hopes, and fears.1
Peabody, 1927
Although such a philosophy should be asserted by
physicians daily in modern medical practice, empathy
alone will unfortunately not protect our patients from
undesirable healthcare events or untoward surgical out-
comes. The surgeon cannot control predictably and reli-
ably the multitude of variables involved in the care of a
surgical patient. Surgical complications inevitably occur
and do so in many varieties and with diﬀ ering degrees
of severity. Untoward outcomes stem from events that
occur intraoperatively or postoperatively and can occur
because of an undesirable patient characteristic (e.g., to-
bacco abuse, diabetes, malnutrition, or willful neglect),
or because of an undesirable surgeon characteristic (e.g.,
technical error or poor judgment).
Unlike the airline industry, in which a successful ﬂ ight
can be deﬁ ned as one that takes oﬀ and lands unevent-
fully without loss of life or limb, surgical complications
occur along a greater spectrum of possible outcomes.
This is especially true in plastic surgery, where the suc-
cess of the outcome is not simply a matter of whether
the ﬂ ap lives or dies or whether the wound heals or does
not; rather, it is a complex interplay of actual results,
intended results, and expected results. At no time is this
more important than when the surgeon’s subject is the
human face, for an undesirable outcome from an opera-
1
1
Facial Plastic Surgery Complications:
An Overview
Randolph B. Capone
Fig. 1.1 Francis Weld Peabody. Used with permission from
J Clin Invest. 1927 December; 5(1): 1.b1–6.

Complications in Facial Plastic Surgery
2
important in aesthetic surgery, it is therefore included
with the more traditional types of surgical complica-
tions, because any outcome whereby the patient is truly
not happy is an undesirable outcome.
Complications in facial plastic surgery are not uni-
formly the result of errors by the surgeon, although it
has been estimated that 60–82% of adverse events in
healthcare might be attributed to human error.3,4 There-
fore, avoidance of the terms “error” or “mistake” in the
previous descriptions is purposeful, so as not to imply
fault. While consulting the chapters of this book, readers
should keep this framework in mind and are encouraged
to develop familiarity with these four forms of causa-
tion. Surgeons can then hope to identify deftly, manage
adeptly, and reconstruct appropriately the cause of their
patient’s unfortunate result, for both the beneﬁ t of the
patient and the prevention of future problems.

◆How Are Complications Avoided?
PATIENT VIGNETTE: A patient desiring revision rhino-
plasty displays columellar malposition with accom-
panying nostril asymmetry. She desires symmetric
nostrils. Her request during consultation is straightfor-
ward, and she instructs the surgeon emphatically, “Just
please make them equal, doctor.” After careful exami-
nation, the surgeon indicates that if given the oppor-
tunity, he would do everything he could to repair her
columella and improve her nostril symmetry, but that
revision rhinoplasty is a challenging operation devoid
of guarantees. Although he shows her photos of previ-
ous patients he has helped with a similar problem, he
emphasizes that many factors aﬀ ect the position of the
skin bridge between the nostrils and that he cannot
know with certainty why she healed this way or what
the prior surgeon did that might have aﬀ ected this area.
During the discussion, he indicates that his surgical fee
is for the attempt, not the result, and he emphasizes
the importance of this distinction. This dialogue helps
modify the expectations of the patient, so that when
after the operation her columellar position and nostril
symmetry appear improved but not perfect, she is still
pleased. If the surgeon had not communicated with
the patient eﬀ ectively, she could easily have been sig-
niﬁ cantly disturbed by the lack of perfection that she
thought she was paying for.
As illustrated, communication between patient and
plastic surgeon is a powerfully helpful tool to avert the
untoward outcome of patient dissatisfaction with the
surgery. Adequately trained and empathic surgeons
who are most adept at the skills of communication will
fare better than others in preventing poor outcomes and
mitigating their resultant sequela. Thorough discussion
and repetitive counseling before scheduling surgery will
give surgeons additional opportunities to judge the pa-
tion on the face is diﬃ cult to conceal in contemporary
society and harbors unique signiﬁ cance:
In civilized man, the face alone remains unclothed
and exposed. An injury resulting in distortion of
the features thus sets the unfortunate individual
apart in a highly organized society where a pre-
mium is placed upon beauty and facial symmetry.
Because disﬁ gurement of the face becomes a seri-
ous social handicap, the surgical treatment of fa-
cial injuries is of special signiﬁ cance, as it serves
to restore the inner feelings of happiness and well-
being in addition to the outer appearance and
function.2
Varstad Kazanjian and John Converse, 1949
This text was conceived and crafted to help surgeons
help their patients, so it is devoted to the prevention,
identiﬁ cation, and management of unfavorable out-
comes in contemporary facial plastic surgery.

◆What Is a Complication?
Plastic surgeons and patients often interpret surgical re-
sults diﬀ erently, and an undesirable result can be real or
perceived. What the surgeon sees as a technical victory,
the patient can easily view as unsightly. To complicate
matters further, an undesirable outcome for one patient
might be overlooked by another or even lauded by yet
another. Despite such variability, there is a consistent
emotion associated with poor surgical outcomes that
all surgeons will inevitably experience during their ca-
reers: the sinking feeling that always accompanies the
appearance of an undesirable result, the associated loss
of patient conﬁ dence, and the uncomfortable torque
that ensues on the patient-doctor relationship.
For the purposes of this text, it is necessary to under-
stand the deﬁ nition of a complication in facial plastic
surgery. Because of the aesthetic nature of the specialty,
the familiar deﬁ nition has been expanded to include
patient dissatisfaction as a complication. Therefore, a
complication can be deﬁ ned as an undesirable outcome
that occurs because of the presence of one or more of
four conditions: (1) inappropriate surgical technique,
(2) inappropriate surgical judgment, (3) inappropriate
recovery, and (4) inappropriate patient expectations.
Inappropriate technique includes both equipment fail-
ure and doing the advisable procedure but performing it
incorrectly. Inappropriate judgment includes both poor
patient selection and doing an ill-advised procedure but
performing it correctly. Inappropriate surgical recovery
includes any aberration in wound healing or other com-
plication that arises in the recovery period, and inap-
propriate patient expectations occur when the surgical
result falls signiﬁ cantly short of the outcome the pa-
tient desired. Because this latter condition is extremely

1 Facial Plastic Surgery Complications: An Overview
3

◆ What Should Be Done When a
Complication Is Identiﬁ ed?
Complications are onerous to surgeons as well as their
patients, and it is a natural coping mechanism for sur-
geons to rationalize, conceal, or deny their presence.
Surgeons typically will want to avoid unhappy patients
altogether, seeing them in the oﬃ ce or visiting them
in the hospital less frequently. Even with weekly mor-
bidity and mortality (M&M) conferences at nearly all
institutions, it is rare for a plastic surgeon to present
electively the patients who did not like their facelifts or
felt their noses were still too big. Understandably, M&M
is reserved for presentation and discussion of “true”
morbidities, and topics concerning questionable mor-
bidities are not usually discussed. But in spite of this,
surgeons should do just the opposite and pay increased
attention to their unhappy patients, listening avidly and
repeatedly to their concerns and being ever present for
their beneﬁ t. Mindful of the saying that recommends
“holding your friends close and your adversaries closer,”
surgeons should seek out their patients who experience
complications. In some cases, they should oﬀ er daily
visits. Listen intently, without trying to explain continu-
ally what might have gone wrong. Never presuppose
what impact a facial plastic surgery complication has on
a patient. Who can say that a facial tic after rhytidec-
tomy is worse than xerophthalmia after blepharoplasty,
or that new nasal obstruction after cosmetic rhinoplasty
tient’s goals and expectations and also to temper them.
It is the responsibility of the surgeon to make patients
understand ﬁ rmly that the goal of facial plastic surgery
procedures is improvement, not perfection. If a patient
has inappropriate or unrealistic motivations or expecta-
tions for surgery, it is ultimately better to refuse to per-
form the surgery or to alter strategy than to proceed.
This is critically important, because typically patients
with the most realistic expectations at the outset are
the ones most enamored with their surgical experience.
Eugene Kern sagely advises that preoperative patient
preparation be taken even a step further and encourages
surgeons to prepare their patients for a second opera-
tion before performing the ﬁ rst.5 Such realistic forecast-
ing brings to mind the saying that one should strive to
underpromise but overdeliver.
Problems in recovery are mitigated by prudent patient
selection, elimination of high-risk individuals, and metic-
ulous postoperative care, while solid surgical experience
and careful preparation will help eliminate problems in
judgment and technique. Surgeons are frequently en-
couraged to perform their procedures three times to help
with preparation and reﬂ ection for future improvement:
once mentally before the case, once physically during the
actual procedure, and once again mentally after comple-
tion of the case. Other techniques for avoiding adverse
outcomes are outlined in Table 1.1; although decidedly
incomplete, the table attempts to organize further this
complex topic by showing how undesirable outcomes in
facial plastic surgery might be avoided.
Table 1.1
Techniques to Help Avoid Adverse Outcomes
Complication Category
Avoidance Techniques
Inappropriate surgical judgment
Inappropriate surgical technique
Solid surgical training
Maintenance of certiﬁ cation
Continuing medical education
Familiarity with current literature
Regular attendance at M&M conferences and journal clubs
Avoid practicing in a vacuum—attend professional meetings
Careful surgeon preparation
Know whom you can help and whom you can’t
Test equipment prior to surgery
Surgical time outs
Surgical site markings
Inappropriate recovery
Meticulous patient selection
Elimination of high-risk individuals
Thorough postoperative patient and caretaker education
Careful performance of postoperative care
Inappropriate patient expectations
Superlative patient communication
Thorough informed consent process
Realistic preoperative imaging display
Review of prior patient photos and outcomes with prospective patients
Encouragement of prospective patients to speak with prior surgical patients

Complications in Facial Plastic Surgery
4
References
1. Peabody FW. The care of the patient. JAMA 1927;88(12):877–
882
2. Kazanjian VH, Converse JM. The Surgical Treatment of Facial
Injuries. Baltimore: Williams and Wilkins; 1949
3. Kohn LT, Corrigan JM, Donaldson MS, Eds. To Err Is Human:
Building a Safer Health System. The Institute of Medicine;
2000
4. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable an-
esthesia mishaps: A study of human factors. Anesthesiology
1978;49(6):399–406
5. Kern EB. The preoperative discussion as a prelude to man-
aging a complication. Arch Otolaryngol Head Neck Surg Nov
2003;129:1163–1165
is worse than malocclusion after facial fracture repair?
Only patients can judge this impact.
Careful reﬂ ection on the course of events and critical
review while driving or in the quiet moments before
sleep can help discover and illuminate any missteps, bad
judgments, technical errors, or insuﬃ cient preoperative
discussions. Surgeons should confer with trusted col-
leagues, either in private or in a collegial meeting format
such as M&M conference. Other surgeons have likely
had similar experiences and can oﬀ er counsel, helping
to convey what should or should not be done.

◆Conclusion
As Francis Peabody suggested to his medical students
nearly 90 years ago, surgeons must sit with and listen
to patients after a complication and be ever empathetic,
for most often this is what patients primarily want from
their surgeons after an undesirable outcome. They want
to know that the surgeon comprehends the gravity of
what they are going through and is there emotionally
to help them bear the burden of an adverse recovery.
Other actions, such as issuing apologies, giving refunds,
and notifying a medical liability carrier, are outside
the scope of this text but might be beneﬁ cial. Consid-
eration of all such factors involved with undesirable
surgical outcomes will help surgeons better understand
the medical, social, and psychological interplay of the
variables, and such an understanding will lead to im-
provements in outcome. Plastic surgery, after all, is not
simply performing the complex or innovative steps that
deﬁ ne a particular procedure; rather it involves taking a
patient with a facial deformity or undesirable trait and
striving to improve form, function, and self-image si-
multaneously. This is a weighty yet rewarding task.
PEARLS OF WISDOM
The secret of the care of the patient is caring for the patient.1
Complication prevention is always the best practice.
Prepare patients for revision surgery before performing the
primary operation.5
Perform each case three times: twice mentally and once physically.
Swift acknowledgment of a complication is paramount.
Be present emotionally and physically for your patients with
untoward results. See them frequently and listen actively.
Patients with the most appropriate expectations are often the
most enamored with their surgical result.

The goals and expectations of patients seeking plastic
surgery are complex. For most patients, the overt desire
is to change their physical appearance or function. How-
ever, patients have unspoken desires, which may in-
clude improving their self-esteem and overall quality of
life. Although unstated, these desires to improve overall
quality of life clearly aﬀ ect an individual patient’s even-
tual satisfaction with his or her surgical outcome.
The goal of the facial plastic surgeon is to achieve the
best possible aesthetic and functional surgical outcome.
However, improved function and aesthetic appearance
are clearly matters of the individual’s perception. An in-
dividual patient’s perception of their surgery is a prod-
uct of many factors that include not only the physical
result but also the less objective characteristics of self-
esteem and ego strength.
This chapter focuses on diagnosis and treatment of the
psychological aspects of the plastic surgery patient. This
includes preoperative identiﬁ cation of the well-adjusted
patient, who is likely to appreciate the beneﬁ ts of well-
performed surgery. The preoperative consultation should
also identify potentially problematic patients. This chap-
ter outlines a systematic approach to evaluate patients
who are likely to be dissatisﬁ ed with plastic surgery and
provides an algorithm for dealing with these patients. A
detailed outline of how to communicate with all patients
is included. Although the plastic surgeon receives mini-
mal training in dealing with the psychological concerns
of the plastic surgery patient, attention to this subject is
mandatory for a successful plastic surgery practice.

◆Preoperative Considerations
The Consultation
The initial consultation between the facial plastic sur-
geon and a prospective patient is a complex interaction
that involves two-way diagnosis and decision making.
While evaluating the medical history and physical suit-
ability of the patient, the surgeon is also beginning a
process of deciding whether or not the patient is a good
psychological candidate for surgery. Simultaneously, the
patient is evaluating the surgeon and deciding whether
to be operated on by the surgeon.
Most patients seeking a plastic surgery consultation
have already considered the process of making a decision
about surgery. Unlike non-cosmetic surgery patients,
who often hope that surgeons will recommend not hav-
ing surgery, plastic surgery patients desire change and
usually request surgery. For this reason, careful commu-
nication during the consultation is essential in estab-
lishing a healthy and open surgeon-patient relationship.
It is important that the surgeon identify characteristics
that may predispose the patient toward postoperative
dissatisfaction with the surgical result.
The personality characteristics of both the patient
and the surgeon are noticeable during the initial con-
sultation. The overt goals of the patient are to evaluate
the competence and expertise of the surgeon; that is, to
answer the question “Will the surgeon be able to im-
prove the function and appearance of my face?” The less
frequently stated goals of whether or not the surgeon
can care for and comfort the patient during the heal-
ing process are at least as important as surgical com-
petence is to the patient. Thus, the decision to choose
a given surgeon is a complex one based on reputation,
perceived competence, empathy, and comfort during
the consultation.
The surgeon also must make an important evalua-
tion of the patient’s psychological proﬁ le during the
consultation. This begins with the surgeon trying to un-
derstand the patient’s position, perspective, and (most
importantly) motivation for having surgery. If the sur-
geon feels that the patient has a poor self-image and is
generally unhappy, the motivation for surgery may be
to create personal happiness. If such patients are disap-
pointed with the surgical results, their resulting dissat-
isfaction is accentuated. Furthermore, if patients have
poor self-image, it is more likely that surgery will not
meet their expectations. The failure to meet patient’s
expectation usually results from a patient’s initial un-
healthy motivation for having surgery. All of these fac-
tors mandate that the surgeon be aware of the patient’s
psychological proﬁ le and communicate any potential is-
sues with the patient preoperatively.
5
2
Management of the Dissatisﬁ ed Patient
Jonathan M. Sykes

Complications in Facial Plastic Surgery
6
photographs depicting their desired results. Perfection-
ist patients often do not understand the limitations of
surgery. In addition, these patients will often be preoc-
cupied with minimal aesthetic problems or deformities.
These patients require a signiﬁ cant time commitment
from the surgeon to explain surgical limitations and to
set appropriate and realistic expectations. If appropriate
surgical expectations are set and limitations of surgery
are outlined in advance, perfectionist patients can be
very pleased with postoperative results.
Patients Critical of Other Surgeons
A patient who is dissatisﬁ ed with prior aesthetic surgery
and is vocally critical of past medical care is a dangerous
patient to treat. The facial plastic surgeon should listen
carefully to how the criticism is spoken. If a patient ex-
plains a prior surgery with an underlying tone of anger,
this patient should be avoided. If the surgeon operates
on the patient before the anger issues are dealt with, the
anger will likely resurface during the postoperative pe-
riod after the revision surgery.
Surgeons often feel that their surgical skill is enough
to overcome the results of prior surgery that led to pa-
tient dissatisfaction. This idea is reinforced by the pa-
tient who states: “Doctor, I know you are the best! You
can ﬁ x me.” The surgeon should not be trapped by the
histrionic patient who appeals to the surgeon’s ego
while criticizing prior care. Surgeons should realize that
such a patient will be quick to criticize them later when
the surgical result falls short of expectations.
The Depressed Patient
Many members of society have periods of depression.
These periods are often helped by mood-elevating pre-
scription medications. However, some people have more
deep-seated endogenous depression that often is not
helped by medication. It is important for the facial plas-
tic surgeon to identify how severe a patient’s depression
is and whether or not the condition is treatable. If the
depression is treatable, many patients will do very well
with proper preoperative teaching and postoperative
empathetic care. If the depression is not well controlled
and the patient has more deeply rooted neuroses, plas-
tic surgery will usually expose and may even accentuate
these problems. It is appropriate for the surgeon to dis-
cuss these issues directly and to schedule multiple visits
or have the patient seek psychiatric consultation prior to
scheduling any surgery.
Body Dysmorphic Disorder (BDD)
Patients with body dysmorphic disorder (BDD) repre-
sent an increasingly growing percentage in the aesthetic
surgeon’s practice. BDD is listed in the DSM-IV under
somatization disorders, but clinically it seems to have
Selecting Patients
The ﬁ rst step to obtaining a successful outcome in fa-
cial plastic surgery is to select the patient carefully. This
requires the surgeon to delve beneath the surface and
to determine the patient’s inner strength and ability to
deal with the postoperative healing process. Surgeons
are taught how and when to operate, but the skill of
knowing when not to operate requires experience and
good judgment. At the end of their careers, surgeons
will rarely be disappointed that they did not operate on
a particular patient; however, operating on the wrong
patient (one with a poor psychological proﬁ le) often
creates anger and frustration for both the patient and
surgeon. To exclude or discourage certain facial plastic
surgery patients from having surgery, the surgeon must
be aware of patient proﬁ les that are problematic. Table
2.1 lists the traits of patients who are predisposed to un-
happiness or dissatisfaction.
The Demanding Patient
Patients who exhibit the need for special treatment from
either the doctor or staﬀ are diﬃ cult to please and will
tend to be dissatisﬁ ed with their surgical results. These
patients will often request special treatment, including
special timing for their appointments. They will often
seem annoyed by or irritated with the manner in which
they are treated. Physicians should listen carefully to
staﬀ warnings regarding these patients, as demanding
patients will often mask these characteristics from their
physicians.
The Perfectionist Patient
Patients who need to control every detail relating to
surgery are also potential problems. These patients ask
many detail-oriented questions and often bring in many
Table 2.1
Behaviors Associated with Body Dysmorphic Disorder2
• Frequent glancing in reﬂ ective surfaces
• Avoidance of mirrors
• Skin picking
• Repeatedly measuring or palpating the defect
• Repeated requests for reassurance about the defect
• Elaborate grooming rituals
• Camouﬂ aging some aspect of the patient’s appearance with
a hand, a hat, or makeup
• Avoiding social situations where others might see the defect
• Social anxiety
• Depressed mood and suicidal ideation

2 Management of the Dissatisﬁ ed Patient
7
the postoperative reactions of family members, friends,
and coworkers.
For all of these reasons, the surgeon should assess the
patient’s self-image and ego strength during all preop-
erative consultations. This assessment should include
the manner in which the patients discuss their own
cosmetic issues. If patients discuss a minor problem as
a major deformity and are self-berating, they are like-
ly to exaggerate postoperative issues such as swelling,
bruising, or minor cosmetic healing irregularities. These
patients will often become very upset postoperatively
with minor criticisms from family and friends. Patients
with poor self-esteem are also likely to judge postopera-
tive results too quickly and with too much volatility; for
example, they are often happy on one visit and upset at
the next. The surgeon should ask questions at the initial
consultation that help to evaluate the patient’s overall
sense of self.

◆ The Surgeon’s Relationship with the
Cosmetic Surgery Patient
Surgeons are taught to diagnose and treat patients. Plas-
tic surgeons are taught surgical techniques to improve
the function and appearance of their patients. However,
most surgeons are not taught techniques for commu-
nicating eﬀ ectively with their patients. Eﬀ ective com-
munication is the key to all successful physician-patient
interaction. Communication is the basis of trust and
understanding.
Communication allows the surgeon to understand
the patient’s motivations for and expectations of sur-
gery. The surgeon should ask questions such as, “When
did you ﬁ rst consider changing your appearance?” and
“Why do you want to change your nose?” The answers
to such questions will give the surgeon insight into the
patient’s goals and motivations. More importantly, the
manner in which the patient answers these and similar
questions will give the surgeon a sense of the patient’s
self-image and the patient’s ability to withstand the
physical and emotional stresses of surgery.
Eﬀ ective communication is especially important in
the postoperative period, when the plastic surgery pa-
tient often feels vulnerable and insecure about the sur-
gical results. It is particularly important that the patient
experiences “being heard” by the surgeon. If the patient
has a postoperative concern, the surgeon should avoid
the tendency to diagnose and treat the problem imme-
diately. The patient usually does not require immediate
treatment (in fact, the surgeon cannot provide this any-
way) but instead needs a listening, caring provider. The
surgeon should use reﬂ ective listening, which includes
repeating or paraphrasing the speaker’s intents. This
technique includes phrases such as, “So it sounds like
you’re saying…,” or “What I hear you saying is…” This
form of listening allows the patients to feel that they are
similarities to obsessive-compulsive disorder (OCD).1
These patients universally are dissatisﬁ ed with them-
selves and want signiﬁ cant changes in their appearance.
They generally have a poor self-image, ﬁ xate on small
aesthetic issues, and allow these issues to become im-
portant and even overwhelming problems.
Their signiﬁ cant distortions in self-image make it
very diﬃ cult to satisfy patients with BDD. They often
desire changes in multiple body parts yet often hide
these wants from the surgeon. Although patients with
BDD desire multiple changes, they are embarrassed by
their wants, because they have some insight into their
narcissistic desires. An example of this behavior is the
patient with anorexia nervosa, who feels too fat but
does not want to share this feeling with others. Patients
with BDD are dangerous for the aesthetic surgeon and
therefore warrant early identiﬁ cation. The other behav-
iors commonly associated with BDD that can be useful
in detecting the condition are outlined in Table 2.1.
These patients usually cannot be satisﬁ ed, as their
underlying problem is poor self-image, and not a desire
to change a single body part or feature. These patients
rarely comprehend the limitations of the plastic sur-
gery and almost always desire multiple procedures. A
patient with BDD commonly asks the question, “When
can we schedule my next procedure?” It is important for
the surgeon to see through the patient’s poor self-image
and to advise them not to have too much surgery. In a
sense, the surgeon must protect patients with BDD from
themselves.
Patients with Poor Self-Image
The self-esteem and self-image of patients vary signiﬁ -
cantly. The personality characteristics of patients range
from those who are totally secure with their status and
image to those who feel inadequate and want to change
themselves totally. Ironically, people with the best self-
image are the best psychological candidates for cos-
metic surgery, but they often do not request surgical
change.
Cosmetic surgery results in some change in self-im-
age. This is often evidenced by patients who have rhi-
noplasty and then change their hairstyles and makeup
postoperatively. If the patient has a positive change in
self-image after the cosmetic surgery change, the pa-
tient will be very happy with the results. However, when
patients have a negative change in self-image, they are
rarely satisﬁ ed postoperatively with the surgical result.
Because the patients’ ultimate evaluations of their
surgical results are based on their preoperative self-im-
age, it behooves the surgeon to evaluate each patient’s
sense of self preoperatively. It is their strength of self-
image that will allow the patients to accept their physi-
cal changes postoperatively, as swelling and bruising
occur and eventually give way to a changed appearance.
A patient’s self-esteem also allows the patient to accept

Complications in Facial Plastic Surgery
8
they are less likely to be angry or frustrated postopera-
tively. It is important for the physician to ensure that
the patient understands the diagnosis and treatment
options. This understanding is essential to successful
patient education.
The last E in successful physician-patient communi-
cation is enlistment. Enlistment is deﬁ ned as an invita-
tion from the clinician to the patient to collaborate in
making the decisions regarding the goals and plans for
treatment. The surgeon should oﬀ er options, explore
the pros and cons of each option, and agree with the pa-
tient on the best option. The patient should be allowed
to weigh all treatment options. This is extremely impor-
tant in elective cosmetic surgery, which is not a need but
a want of the patient. If the patient understands that the
surgery is something that they desire but do not need,
there is less chance for postoperative dissatisfaction. By
engaging patients in the process and enlisting them in
the decision-making, the surgeon converts patients into
partners.

◆Managing the Dissatisﬁ ed Patient
Dissatisfaction after cosmetic surgery produces distress
in both the patient and the surgeon. Even though only
a relatively small percentage of cosmetic surgery pa-
tients are truly dissatisﬁ ed with their result, these few
patients usually occupy a large amount of the surgeon’s
time and energy. Learning to deal with patient dissatis-
faction after cosmetic surgery requires the surgeon to
gain signiﬁ cant psychological skills.
The key to dealing with postoperative patient dis-
satisfaction is communication. As noted in the section
above, successful communication requires empathy
and compassionate listening. This will allow the sur-
geon to identify the speciﬁ c reason(s) for the patient’s
dissatisfaction. It is important for the surgeon to avoid
the impulse to immediately suggest a solution for the
problem; rather, the surgeon should listen carefully and
express compassion for the patient. The surgeon should
approach the patient with postoperative issues in the
same manner that is used during the initial consulta-
tion; i.e., the surgeon should use a systematic commu-
nication style that employs all four Es. This will allow
the surgeon to display empathy and compassion to the
patient and will usually prevent anger and frustration
by the patient.
The usual cause of patient dissatisfaction after aes-
thetic surgery is unmet expectations. Patient often ex-
pect that cosmetic surgery improve their self-image
and self-conﬁ dence. In most patients, this is the case.
However, for some patients who have signiﬁ cant pre-
operative issues with their self-image, the surgery ac-
tually causes an erosion of self-esteem. Naturally, such
patients then transfer their feelings of loss of conﬁ dence
and self-image onto the surgical result. These patients
being heard. The use of these communication skills will
allow the surgeon to avoid the frustration and anger that
often accompany the dissatisﬁ ed postoperative patient.

◆ The Four Es of Eﬀ ective
Communication
The clinician can use a systematic approach to improving
communication with patients. The four Es of commu-
nication—engage, empathize, educate, and enlist—give
the provider a model to use in any patient interaction.
These communication skills are useful during both pre-
operative consultations and postoperative visits. The
four Es are especially eﬀ ective in dealing with diﬃ cult,
demanding, or dissatisﬁ ed patients.
Engagement is the initial connection with the patient.
This includes orienting the patient to the process of the
visit or the care to be given. It is important that the prac-
titioner elicit statements about the patient’s goals and
expectations and identify all complaints. The physician
should be curious about the person prior to examining
the patient. The person is engaged with statements such
as, “Before we begin, tell me something about yourself.”
The agenda is engaged with statements such as, “What
were you hoping to accomplish today?”
The ability to empathize with patients is very impor-
tant in all ﬁ elds of medicine but is particularly crucial in
plastic surgery. Empathy allows the surgeon to accept
the patients’ perspectives and to understand their mo-
tivations for surgery. To empathize with the patient, the
surgeon must be a caring listener. The patient should
experience being heard and accepted. The surgeon can
use reﬂ ective listening to allow the patient to experi-
ence being heard. Reﬂ ective listening involves repeating
what the speaker says to guarantee that the speaker’s
words and meaning are understood. The surgeon should
use short summaries to reﬂ ect what they hear. The sur-
geon can use stems such as, “So, you are saying that…”
or “You are wondering if…,” or “I hear you saying….”
The technique of reﬂ ective listening should be used in
all patient interactions, beginning with the consultation
and continuing through all postoperative care.
Education of patients is fundamental to all successful
communication with patients. The patient should feel
as though there is shared knowledge in diagnosis and
in treatment options. The surgeon should ask patients
about their understanding of the condition, why it is
occurring, and what they know about possible treat-
ments. This will allow the patient to better accept the
surgeon’s viewpoint and better assess the treatment
options presented. This is particularly important with
cosmetic surgery patients, who may be inundated with
multiple surgical options from the media and Internet.
If patients feel as though they have made educated de-
cisions preoperatively regarding their surgical choices,

2 Management of the Dissatisﬁ ed Patient
9
nication and to learning psychological skills. Although it
is important for all surgeons to maximize their surgical
skills, the success of any cosmetic surgeon’s practice is
related to the surgeon’s ability to interact with patients.
Careful selection and screening are crucial to patient sat-
isfaction. Use of a systematic method—the four Es—gives
the surgeon a consistent template for communication. If
communication is used eﬀ ectively, facial plastic surgery
can be rewarding for both the patient and the surgeon.
will become extremely sensitive to the reactions and
comments of family members and friends. In addi-
tion, such patients will often become overly concerned
with normal postoperative swelling and bruising and
will become impatient with normal healing times. It is
very important that the surgeon recognize the patient’s
insecurity over the postoperative healing and surgi-
cal results. It is more important to show these patients
compassion and empathy than it is to try assuring them
that their healing is “normal.”
As discussed in the “Selecting Patients” section, the
best method for obtaining a successful outcome in plas-
tic surgery is to select patients carefully. If a patient has
signiﬁ cant postoperative dissatisfaction and communi-
cation between the patient and the surgeon erodes, the
surgeon should use other means to communicate with
the patient. This includes using friends and family of the
patient to assist communication. Often, a friend or fam-
ily member may add reason and may help the patient
articulate his or her concerns and dissatisfaction. The
surgeon should also use a caring staﬀ member to attend
all postoperative visits. The presence of other people
(staﬀ members and family members) during the visit
will foster communication and help avoid anger and
frustration. It is very important to document all visits
carefully and to have staﬀ members document their im-
pressions of the visit separately.
In rare cases, the erosion of communication results
in increased patient frustration and increased surgeon
distress. The patient will occasionally ask for a ﬁ nancial
refund. The surgeon should then consult risk manage-
ment specialists and their insurance carrier. In these
instances, a refund or partial refund of the surgeon’s
fee may be given, but it should be given only after the
patient signs a full liability release. The refund of fees
should terminate the relationship between the surgeon
and patient.

◆Conclusion
In training for facial plastic surgeons, the emphasis is on
learning surgical technique. Very little time and educa-
tion are devoted to improving surgeon-patient commu-
PEARLS OF WISDOM
It is important that the surgeon determine the patient’s moti-
vations for, and expectations of, surgery.
Patient selection in plastic surgery is as important as surgical
execution.
Certain personality types predispose the patient to postopera-
tive unhappiness or dissatisfaction. These include the demand-
ing, the perfectionist, and the depressed patient.
Patients with body dysmorphic disorder (BDD) frequently
request aesthetic surgery. These patients have signiﬁ cant dis-
tortion in self-image and are diﬃ cult to satisfy surgically.
The four Es of eﬀ ective communication—engage, empathize,
educate, and enlist—allow the provider a model to use in any
patient interaction.
The surgeon should use reﬂ ective listening when interacting
with the patient. This will allow the patient to feel understood
and accepted.
Successful methods for dealing with postoperative patient dis-
satisfaction include listening and understanding the patient.
References
1. Jakubietz M, Jakubietz RJ, Kloss DF, Gruenert JJ. Body dysmor-
phic disorder: diagnosis and approach. Plast Reconstr Surg
2007;119(6):1924–1930
2. Phillips KA. The Broken Mirror: Understanding and Treat-
ing Body Dysmorphic Disorder. New York: Oxford University
Press; 1996:391

10
Intradermal and hypodermal injections have become a
multimillion dollar industry in contemporary cosmetic
medicine. Minimally invasive facial rejuvenation tech-
niques, such as soft-tissue augmentation with dermal
ﬁ llers and rhytid eﬀ acement with botulinum neurotoxin
type A (BT-A), have exponentially increased in popular-
ity. This increase in popularity and demand is due to a
combination of fast results with minimal recovery time
as well as excellent product safety records. As more pa-
tients seek cosmetic and aesthetic improvement with-
out surgery, a review of the potential complications that
can occur from these minimally invasive techniques can
be advantageous. By reviewing complications associated
with the most often used injectables, both the physician
and the patient will become better informed of both po-
tential complications and expected results. This chapter
will discuss BT-A, review its associated complications,
outline the most commonly used injectable ﬁ llers, and
brieﬂ y discuss the potential complications associated
with each product: collagens, hyaluronic acids, Radiesse,
Sculptra, and synthetic injectables.

◆Botulinum Toxin
Botulinum toxins have been used successfully to manage
facial aging by eﬀ acing rhytides and hyperkinetic lines
of the face and neck. Although seven diﬀ erent serotypes
of botulinum toxin are found in nature (A through G),
serotype A is the most commonly used [Botox and Botox
Cosmetic (Onabotulinum toxin A), Allergan, Inc., Irvine
CA. Dysport (Abobotulinum toxin A), Medicis Aesthet-
ics, Inc., Scottsdale, AZ. Xeomin (Incobotulinum toxin A),
Merz Aesthetics, Inc., San Mateo, CA]. Each of the sero-
types is deﬁ ned by its speciﬁ c biologic action, speciﬁ -
cally the cleaving of diﬀ erent proteins involved in active
transport of acetylcholine into the neurosynaptic cleft
responsible for muscle contraction. Relaxing the muscle
leads to eﬀ acement of rhytides, causing an improved
cosmetic appearance. Although extensive research and
data have been collected to support the safety of BT-A in
therapeutic doses, it is important to note that complica-
tions can occur. Complications related to BT-A are usu-
ally minimal, short-lived, and reversible. The majority
of complications can be prevented with proper injection
techniques, correct dosing, and a thorough knowledge
of facial anatomy.
Potential Complications with BT-A Injections
Bruising, Pain, and Edema
Bruising, pain, and edema can occur from BT-A injec-
tions; however, it should be noted that they are usually
associated with the injection itself and are not complica-
tions of the neurotoxin. Mild bruising has been reported
in as many as 11% to 25% of patients who received Botox
injections.4 Bruising is increased in patients taking non-
steroidal anti-inﬂ ammatory drugs, aspirin, anticoagu-
lant medications, vitamin E, or large doses of ginseng,
garlic, and ginkgo. Patients should be advised to discon-
tinue taking these products 7 to 10 days before treat-
ment if medically possible.
Injection site pain is an adverse event associated with
any injection, but it can be minimized with the use of a
topical lidocaine (Topicaine, ESBA Laboratories, Moun-
tain View, CA) and benzocaine, lidocaine, tetracaine
(BLT, TLC Pharmacy, Hermosa Beach, CA). Both pain
and edema can each be minimized by applying ice to
the injection sites directly after injection. The use of
32-gauge needles will also help to minimize bruising
and discomfort.
Immunogenicity
Immune responses to BT-A have occurred in patients
receiving local injections of botulinum toxin (BTX). De-
velopment of antibodies and T lymphocytes primed to
epitopes on the heavy chain of the toxin has been re-
ported.4 Loss of action can occur in patients who have
received one or more previous BTX injections; upon a
3
Complications in the
Cosmetic Oﬃ ce Setting
Corey S. Maas

3 Complications in the Cosmetic Oﬃ ce Setting
11
Correct patient selection is also an important consid-
eration to avoid brow ptosis. Patients with heavy, thick
brows should be avoided, as well as patients who had
brow ptosis before receiving botulinum toxin.
Blepharoptosis (Figs. 3.1, 3.2)
Bepharaptosis (eyelid) ptosis is deﬁ ned as inferior mal-
position of the upper eyelids; it can occur from the use
of BT-A and most commonly occurs when BT-A is in-
jected into the orbicularis oculi, corrugator supercilii
and procerus muscles5 (Fig. 3.1). Eyelid ptosis usually
occurs from either incorrect placement of BT-A or diﬀ u-
sion of the toxin through the orbital septum to the leva-
tor palpebrae superioris muscle. The onset of ptosis can
range from 48 hours up to 14 days after the injection and
can last for two to four weeks. Blepharoptosis is usually
subtle; however it can become exaggerated at the end of
the day or when patients feel tired. Ptosis can very easily
be avoided by advising patients to avoid manipulation
and to remain in the upright position for 3 to 4 hours
after the injection. Injections to reduce glabellar rhytides
should not be performed lateral to the midpupillary line.
subsequent injection, the patient does not respond to
treatment. Although BT-A resistance occurs in only 5%
of patients, it is an important factor to consider.1 This
immunogenicity is presumed to be caused by the for-
mation of serum antibodies.4 The antibodies formed
against BT-A can block the activity of the neurotoxin by
blocking the presynaptic terminals, thereby allowing
the release of acetylcholine and leaving the patients as
nonresponders. Resistance can be measured using the
Frontalis Type A Antibody Test (FTAT), where patients
are injected with 15–20 units of BT-A in the frontalis
muscle. The patient is considered a nonresponder or re-
sistant if the eyebrows can be raised after two weeks.2
The immunogenicity of BT-A is thought to be dependent
on the amount used, the duration between injections, and
the amount of protein surrounding the toxin. It has been
noted that repeat treatments with large doses may in-
crease the likelihood of developing antibodies.3 Immune
response can be minimized by using the smallest eﬀ ec-
tive dose and by increasing the amount of time between
injections. BT-A has a large therapeutic window, which in-
creases the possibility of overtreatment. As a simple rule,
the minimal eﬀ ective dose should be used to give maxi-
mum eﬃ cacy with a lower risk of developing immunoge-
nicity. Because the protein content may be proportional
to antigenicity, Botox has released recent batches with
lower protein content in the hope of decreasing immuno-
genicity.3 Dysport, another serotype A toxin, was recently
approved by the FDA and has a lower protein load.4
In patients who have demonstrated nonresponsive-
ness, diﬀ erent serotypes of the botulinum neurotoxin
may result in diﬀ erent antibody responses, thus sero-
type B (Myobloc) may be an option for these patients.
Brow Ptosis
BT-A is commonly injected into the frontalis muscle to
reduce transverse forehead rhytides. However, over-
treatment of the frontalis muscle can produce brow pto-
sis, a complication resulting in a drop of the brow below
the supraorbital rim. Brow ptosis can be easily avoided
by reviewing facial anatomy and using correct injection
techniques, as well as adhering to patient selection cri-
teria. The frontalis muscle lies beneath a thick layer of
sebaceous skin and subcutaneous tissue. The muscle
originates on the galea aponeurotic layer superiorly and
interdigitates with the procerus, corrugator and orbicu-
laris oculi muscles that overlie the brow region. Success-
ful rejuvenation of the rhytides requires some relaxation
of the frontalis muscles, but not enough to cause sub-
sequent brow ptosis through the unopposed drepressor
activity of the procerus, corrugator and orbicularis oculi
muscles. Deep injections into the muscle are performed
in a staggered distribution, with ~1 cm distance between
injections positioned at least 1.5 cm to 2.0 cm above the
brow margin. If injections stay above the brow, subse-
quent ptosis and brow asymmetry are avoided.
Fig. 3.1 Patient with eyelid ptosis of left lid.
Fig. 3.2 Patient with eyelid ptosis of left lid. Note attempted
frontalis compensation (elevated left eyebrow).

Complications in Facial Plastic Surgery
12
growing, making it increasingly important to discuss
the proper usage and potential complications associated
with each product. Some commonly used FDA-approved
ﬁ llers are outlined below.

◆Bovine, Porcine, and Human Collagen
Collagen has been used as a soft-tissue ﬁ ller since the
1980s, and its popularity peaked in the 1990s. Although
no longer in signiﬁ cant use, it is included in this discus-
sion largely for historical purposes. The most abundant
protein in the body, collagen acts as a successful, non-
permanent biocompatible treatment for soft-tissue
deﬁ ciencies. Cells from animals, including cows and
pigs, are a useful source of collagens (Evolence, Ortho-
McNeil-Janssen-Pharmaceuticals, Inc., Los Angeles, CA).
The ﬁ rst bovine collagen approved for soft tissue aug-
mentation was Zyderm (Palo Alto, CA). Bovine collagen
comes in three types, produced by Inamed Aesthetics
(Santa Barbara, CA). Zyderm I received its FDA approv-
al in 1981 and became the ﬁ rst non-autologous agent
approved in the United States for use in soft-tissue
augmentation.9 The approval of Zyderm II and Zyplast
quickly followed. Zyderm is a preparation of bovine
collagen that has been puriﬁ ed, digested with pepsin,
and suspended in phosphate-buﬀ ered saline with 0.3%
lidocaine.10 Zyderm II has a higher concentration of col-
lagen (6.5% compared with 3.5% in Zyderm I). Zyplast
is collagen cross-linked with glutaraldehyde, leading to
longer durability with a decrease in antigenicity.11 The
eﬀ ects of bovine collagen treatments last between 3
and 6 months.
Cosmoderm and Cosmoplast, approved by the FDA
for cosmetic use in 2003, are bioengineered human col-
lagens used to correct facial rhytides. These products
contain puriﬁ ed collagen derived from cell cultures of
human ﬁ broblasts. The cell lines are screened for virus-
es, tumorigenicity, and other potential pathogens; the
collagen produced is devoid of antigenic determinants,
which makes the product nonimmunogenic and thus
eliminates the need for a skin test.

◆Hyaluronic Acid
Hyaluronic acid (HA) is a naturally occurring polysac-
charide found in all living organisms that has virtually
supplanted the use of collagens for cosmetic purposes.
HA ﬁ llers are nonimmunogenic and therefore bypass
the need for skin testing. HA ﬁ llers are also strongly hy-
drophilic, which serves to hydrate and plump the skin.
A rapidly developing area, there are eight formulations
currently approved by the FDA at the time of this writ-
ing: Restylane, Perlane (Medicis Aesthetics, Inc., Scott-
sdale, AZ), Prevelle Silk (Mentor Corporation, Santa
Barbara, CA), Captique (Inamed Aesthetics, Santa Barba-
If ptosis occurs, the use of apraclonidine eye drops,
0.5% (Iopidine, Alcon Laboratories, Forth Worth, TX)
can be an eﬀ ective therapy.6 Apraclonidine is an α2-
adrenergic agonist, causing contraction of the Müller
muscles and a resulting elevation of the eyelid. One or
two drops should be applied three times daily until pto-
sis resolves. It is important to note that contact dermati-
tis has been noted as a potential complication with use
of apraclonidine.7
Systemic Complications of BT-A
Systemic complications are not an issue when botulinum
toxin is used in small quantities with standard prepara-
tions. There are, however, reports that botulinum toxin
has been detected in the hypothalamus after intrader-
mal injection, which would indicate it travels systemi-
cally and even crosses the blood-brain barrier. There
have also been misadventures with treated individuals
contracting systemic toxicity (botulism) after injections
of botulinum toxin when non-standard preparations
and large doses were used. It is imperative, therefore,
that physicians who treat patients with botulinum toxin
use only the recommended doses of FDA-approved tox-
ins. Whatever the actual mechanism, the lack of del-
eterious systemic eﬀ ects with these simple guidelines
implies that while research into BT-A mechanisms con-
tinues, physicians can safely use BTX for therapy.8

◆Dermal Fillers
Throughout the aging process, elasticity and collagen
levels decrease, creating wrinkles in a fairly predictable
manner. As a corrective measure, dermal ﬁ llers oﬀ er a
successful method for soft-tissue augmentation and fa-
cial rejuvenation without the risks associated with sur-
gery. Thus, as these products gain popularity and more
products emerge, it becomes increasingly important
to discuss the diﬀ erences between the products and
the complications involved with each. For all dermal
ﬁ llers, the potential complications can be divided into
either early or late complications. Early complications,
which can be seen with all ﬁ llers, include bruising, ery-
thema, and edema. Late complications are usually due
to an immunological response or an incorrect injec-
tion technique. The following sections thoroughly dis-
cuss the potential complications associated with each
ﬁ ller and review strategies to avoid and treat adverse
events, so complications can be minimized and hope-
fully avoided.
Nasolabial folds, perioral lines and lips are the most
commonly treated areas; however, dermal ﬁ llers can
also be used for many other corrections, such as gla-
bellar lines, marionette lines, scarring, cheek augmen-
tation, chin and jaw line contouring, and lipoatrophy.
The list of dermal ﬁ llers and areas of use are constantly

3 Complications in the Cosmetic Oﬃ ce Setting
13
Silikon (Fig. 3.4)
Silikon 1000 (puriﬁ ed polydimethylsiloxane) is a highly
puriﬁ ed long-chain polydimethylsiloxane trimethylsi-
loxy terminated silicone oil. It is sterile, not pyrogenic,
clear, and colorless, and it has a viscosity of 1000 cs. Si-
likon 1000 has been approved by the FDA for prolonged
retinal tamponade since 1998. Silikon is also considered
a permanent ﬁ ller.

◆ Potential Complications with
Dermal Fillers
Although some complications are unique to speciﬁ c ﬁ ll-
ers, many complications can be seen with all of the ﬁ ll-
ra CA), Hylaform, HylaformPlus (Biomatrix, Ridgeﬁ eld,
NJ), Juvederm Ultra, and Juvederm Ultra Plus (Allergan,
Inc. Irvine, CA). All are nonanimal stabilized hyaluronic
acids (NASHAs), except Hylaform and Hylaform Plus,
which are a cross-linked variety derived from rooster
combs. Restylane, Perlane, Juvederm Ultra, and Juve-
derm Ultra Plus are cross-linked and are derived from
bacterial fermentation.12 This process causes Restylane
and Juvederm to contain up to four times as much pro-
tein as Hylaform for the same volume. Both products are
safe, but since Restylane and Juvederm are not derived
from an animal source, there is a lower risk of an allergic
skin reaction 13

◆Calcium Hydroxylapatite
Radiesse (Merz Aesthetics, Inc., San Mateo, CA) is a non-
immunogenic synthetic material composed of micro-
scopic calcium hydroxylapatite particles ranging in size
from 25 to 40 μm and suspended in a carboxymethyl-
cellulose gel. As the polysaccharide gel degrades, new
tissue inﬁ ltrates and surrounds the hydroxylapatite
particles. Thus it acts as a framework for new tissue in-
growth. These eﬀ ects last from 12 to 24 months.

◆Poly-L-Lactic Acid
Sculptra (Sanoﬁ Aventis Inc., Bridgewater, NJ) is a syn-
thetic, nontoxic, nonimmunogenic injectable form of
poly-L-lactic acid, a biocompatible and biodegradable
compound that has been used in absorbable suture ma-
terial for over 40 years. Sculptra is composed of crystal-
line microparticles of poly-L-lactic acid. It is packaged as
a sterile, freeze-dried powder, which must be reconsti-
tuted with sterile water, typically with lidocaine.
Proper reconstitution and massage have proven to be
very important in decreasing the possibility of nodule
formation. The original reconstitution volume, which
used 2 cc of saline, was problematic. It was noted that
using a larger amount of diluent (5 to 10 cc of saline)
with longer reconstitution time (a minimum of 12
hours) decreased the risk of nodule formation.14 The
addition of lidocaine to the product just prior to injec-
tion has led to enhanced patient comfort.
Polymethylmethacrylate (Fig. 3.3)
ArteFill (Suneva Medical, San Diego, CA) is an injectable
ﬁ ller used for long-lasting aesthetic results. Consisting
of homogeneous polymethylmethacrylate (PMMA) mi-
crospheres ranging from 32 to 40 microns in size, it is
evenly suspended in a solution of partly denatured bo-
vine collagen and therefore requires a skin test prior to
use. It is considered a permanent ﬁ ller, because the mi-
crospheres are not biodegradable.
Fig. 3.3 Patient with polymethylmethacrylate granulomata in
the nasolabial folds.
Fig. 3.4 Patient with periocular granulomata from silicone
injections.

Complications in Facial Plastic Surgery
14
of an allergic reaction. When bovine collagen (Zyderm)
is used, a skin test is necessary and extremely impor-
tant to determine if the patient experiences any allergic
response to the product. Usually, a skin test of 0.1 mL
is placed intradermally in the volar forearm area. Upon
exposure, a positive skin test is indicated by the devel-
opment of a wheal characterized by edema, erythema,
pain, and itching. A positive skin test is seen in 3.0% to
3.5% of patients. More importantly, there is a 1.3% to
6.2% false-negative rate in skin testing.17 For this reason,
a second skin test is recommended two weeks after the
initial test. Treatments can begin two to four weeks after
a second negative skin test. Hypersensitivity reactions
are indicated by erythema, edema, pain, and tender-
ness. When hypersensitivity occurs, it can be treated
with hydrocortisone cream. Abscess formation is a rare
occurrence, but it is thought to be related to hypersen-
sitivity.18 Severe hypersensitivity is very rare; however,
there have been reports of anaphylactic shock.19
Most of the hyaluronic acid ﬁ llers are of nonanimal
origin and therefore have a very low risk of hypersen-
sitivity reactions. Rare cases of hypersensitivity to hy-
aluronic acid are thought to be due to impurities of
bacterial fermentation or potentially from bioﬁ lm for-
mation. Hypersensitivity reactions comprised 0.02% of
all injections.20 These consisted of swelling, erythema,
and induration at the implant site, with a median dura-
tion of 15 days.21
Tyndall Eﬀ ect
The Tyndall eﬀ ect is caused by the fact that diﬀ erent
wavelengths of light scatter diﬀ erently, depending on
ers outlined above. Complications common to all ﬁ llers
will be discussed below, as well as ﬁ ller-speciﬁ c adverse
eﬀ ects.
Bruising, Pain, Erythema, and Edema
Bruising, pain, erythema, and edema can occur directly
after treatment with any ﬁ ller. These complications are
usually caused by the injection itself and should not
necessarily be attributed to the product. However, cer-
tain precautions can be taken to minimize these events.
Bruising can be minimized by advising patients who are
taking aspirin, vitamin E, and NSAIDs to stop using these
products 7 to 10 days before treatment, if medically ad-
visable. Pain can be decreased by using local nerve block
anesthesia in combination with topical anesthetics, such
as Topicaine or BLT, and with ice. Erythema and edema
can be minimized by advising patients to use ice packs
after the injection.
Vascular Occlusion
Direct injection of any ﬁ ller into the lumen of a vessel
can cause vascular occlusion, leading to ischemia or
(more signiﬁ cantly) irreversible tissue necrosis. Injec-
tions of ﬁ llers into the glabellar region have a higher
risk of vascular occlusion than those into the nasolabial
folds. Vascular occlusion is very rare (estimated at less
than 0.001%), and its occurrence can be reduced with
appropriate technique and correct placement. Bolus
injections with overlying skin tumescence should be
avoided, and injections into areas at increased risk must
be done with elevated caution. Knowledge of vascular
anatomy is important, and injections should be oriented
orthogonal to the lumen of known vessels to limit in-
traluminal injections. Checking for bloody ﬂ ashback be-
fore injection is helpful. Recent developments in needle
design, with emphasis on blunt cannula delivery, might
prove helpful for reducing the incidence of intravascular
injections.
Suspected necrosis or arterial occlusion subsequent
to dermal ﬁ ller injection should be treated aggressively.
Immediate cessation of the injection, vigorous massage,
warm compresses, 2% nitroglycerin paste, and hyperbaric
oxygen therapy have been used with beneﬁ t.15 An addi-
tional protocol for the treatment of impending necrosis
after dermal ﬁ ller injection has been published16 but its
eﬃ cacy has yet to be shown deﬁ nitively (Table 3.1).
Hypersensitivity
While a hypersensitivity reaction can theoretically oc-
cur with any ﬁ ller, this complication is much more com-
mon with ﬁ llers derived from animal products. In fact,
the major drawback to using bovine collagen is the risk
Table 3.1
Vascular Occlusion: Treatment Options
1. Inject hyaluronidase (Vitrase, ISTA Pharmaceuticals, Inc.,
Irvine, CA), 10–30 units diluted 1:1 with saline, at the ﬁ rst
recognition of vascular compromise.
2. Nitropaste (nitroglycerin ointment, 2%) applied to the af-
fected watershed area of compromise.
3. Aspirin, 325 mg each day.
4. Warm compresses and massage.
5. Topical Dermacyte (Oxygen Biotherapeutics, Inc., Durham,
NC), an oxygen cosmeceutical, applied to the area of con-
cern q.i.d.
6. See the patient daily. If there is no improvement, repeat
regimen and add a Medrol dose pack.

3 Complications in the Cosmetic Oﬃ ce Setting
15
ing to inﬂ ammation and the build-up of various epi-
thelioid cells and lymphocytes. Clinically, granulomata
are characterized by erythema and edema. They often
will enlarge if left untreated. Granulomata lack a well-
deﬁ ned border, making excision diﬃ cult. Hence, local
steroid therapy is the suggested treatment protocol.
Kenalog (1mg/cc) injections every four to six weeks can
be beneﬁ cial in reducing the size and appearance of a
granuloma.
With the large number of dermal ﬁ llers on the mar-
ket, it is important to remember that thorough product
knowledge and correct injection technique play major
roles in minimizing the potential adverse events as-
sociated with injectable ﬁ llers. There are three basic
techniques used with injectable ﬁ llers to deliver mate-
rial to the deep dermis or subcutaneous level: linear
threading, droplet, and serial puncture. Linear thread-
ing refers to delivering the product in a uniform, ret-
rograde fashion while the needle is slowly withdrawn
from the tissue. Linear threading is a useful technique
that is very eﬀ ective for lip augmentation along the
mucocutaneous border as well as for augmentation of
the nasolabial fold. The development of blunt cannulas
for injections has made the linear threading technique
most popular, and it purportedly reduces the incidence
of bruising and intravascular injection. The droplet
technique is used in a manner similar to that in linear
threading, except that instead of an even distribution
of ﬁ ller as the needle is withdrawn, microdroplets of
ﬁ ller are delivered into the tissue by gentle pumping
on the syringe as the needle is withdrawn. This tech-
nique has been advocated for injecting silicone. Finally,
the serial puncture technique involves the delivery of
small aliquots of ﬁ ller at multiple spots, with the goal
of an even distribution over a two-dimensional area.
Using the proper technique for each ﬁ ller can help min-
imize complications.

◆Conclusion
The use of botulinum toxin and dermal ﬁ ller injec-
tions slows the appearance of facial aging. The loss of
facial volume can be mitigated with ﬁ llers, and botuli-
num proteins relax unwanted hyperkinetic lines. The
results that have been obtained from these products
have caused an overwhelming surge of products to the
market, and more are in the midst of clinical trials. With
the success of such injectables, limited restrictions on
physician specialty use, and the rise of nonphysician
injectors, more complicated outcomes have followed.
The complications discussed can be minimized with
thorough product knowledge, use of correct injection
techniques, intimate knowledge of facial anatomy, and
adherence to safe practices.
the size of particles they encounter. Because blue and
violet light have the shortest wavelengths in the visible
spectrum, they are more easily scattered than any other
color. This physical phenomenon is related to the ap-
pearance of skin and veins. A vein appears blue, in part,
because longer wavelengths of light (e.g., red) travel
deeply enough into the skin to be absorbed and shorter
wavelengths are scattered, giving the vein a bluish hue.22
Subdermal injection of any clear ﬁ ller can lead to the
Tyndall eﬀ ect. An inexperienced injector may inject too
superﬁ cially, leaving a bluish discoloration at the injec-
tion sites. Therefore, HAs should be injected in the mid
to lower dermis to avoid this complication. If this com-
plication arises, it is fortunately reversible with ﬁ ller
degradation using hyaluronidase, with aspiration of the
product or with the use of selective photothermolysis.
Hyaluronidase, an enzyme not requiring ATP, catabo-
lizes HAs. The use of a small amount of hyaluronidase
(10 to 30 units) can dissolve the HA ﬁ ller and correct the
problem. The QS 1064 nm laser has also been used as an
eﬀ ective therapy.22
Nodules
Nodules are a relatively common complication that can
be seen with any soft-tissue ﬁ ller. Most nonerythema-
tous nodules result from uneven distribution of product
and are not due to an allergenic response. The size of a
nodule tends to remain constant until it is absorbed or
removed. If nodules or lumps result from superﬁ cial in-
jection of product, they can be unroofed and excised us-
ing a 19-gauge needle. Despite its eﬃ cacy in other parts
of the face, Radiesse has a higher incidence of nodule
formation in the lips and is therefore not recommended
in this area. It is thought that with excessive lip motion,
the hydroxylapatite becomes clumped together to form
nodules.
Nodules can theoretically result from an immune re-
sponse to ﬁ llers. These nodules may or may not be pain-
ful and can manifest in the dermis or subcutaneously.
There have been reports of painful erythematous nod-
ules evolving into abscesses.23,24 The important thing to
note is the time of onset of the nodules. If they occur
within the ﬁ rst few weeks of treatment, they are usually
simply due to uneven distribution of the product. How-
ever, when a delayed reaction is seen, it is more likely
caused by an allergic response.
Granulomata
Foreign body reactions can occur from the injection of
certain dermal ﬁ llers and may result in the formation
of granulomata. These occur at a rate 0.01% to 1.0%, de-
pending on the ﬁ ller.1 A granuloma forms as a result of
a foreign body that causes an immune response lead-

Complications in Facial Plastic Surgery
16
13. Lowe NJ, Maxwell CA, Lowe P, Duick MG, Shah K. Hyaluronic
acid skin ﬁ llers: adverse reactions and skin testing. J Am Acad
Dermatol 2001;45(6):930–933
14. Lam SM, Azizzadeh B, Garvier M. Injectible poly-L-lactic acid
(Sculptra): Technical considerations in soft-tissue contouring.
Plast Reconstr Surg 2006; 118(3, Suppl):55–63
15. Narins RS, Jewell M, Rubin M, Cohen J, Strobos J. Clinical Con-
ference: Management of rare events following dermal ﬁ ll-
ers—focal necrosis and angry red bumps. Derm Surgery 2006;
32(3):426–434
16. Dyan SH. Merge September/October 2010: 22–23
17. Klein AW, Rish DC. Injectable collagen update. J Dermatol Surg
Oncol 1984;10(7):519–522
18. Hanke CW, Higley HR, Jolivette DM, Swanson NA, Stegman
SJ. Abscess formation and local necrosis after treatment with
Zyderm or Zyplast collagen implant. J Am Acad Dermatol
1991;25(2 Pt 1):319–326
19. Mullins RJ, Richards C, Walker T. Allergic reactions to oral,
surgical and topical bovine collagen. Anaphylactic risk for sur-
geons. Aust N Z J Ophthalmol 1996;24(3):257–260
20. Matarasso SL, Carruthers JD, Jewell ML. Consensus recom-
mendations of soft-tissue augmentation with nonanimal sta-
bilized hyaluronic acid (Restylane). Plast Reconstr Surg 2006;
117(3, Suppl):3–34
21. Friedman PM, Mafong EA, Kauvar AN, Geronemus RG. Safety
data of injectable nonanimal stabilized hyaluronic acid gel
for soft tissue augmentation. Dermatol Surg 2002;28(6):
491–494
22. Hirsch RJ, Narurkar V, Carruthers J. Management of injected
hyaluronic acid induced Tyndall eﬀ ects. Lasers Surg Med
2006;38(3):202–204
23. Hönig JF, Brink U, Korabiowska M. Severe granulomatous aller-
gic tissue reaction after hyaluronic acid injection in the treat-
ment of facial lines and its surgical correction. J Craniofac Surg
2003;14(2):197–200
24. Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Arte-
rial embolization caused by injection of hyaluronic acid (Re-
stylane). Br J Dermatol 2002;146(5):928–929
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3. Klein AW. Contraindications and complications with the use of
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PEARLS OF WISDOM
Injection of botulinum toxin inferior to the eyebrows or lateral
to the midpupillary line risks blepharoptosis.
Injection of the lateral frontalis muscles risks brow ptosis,
with resultant decompensation and aggravation of underlying
blepharoptosis.
Use the smallest possible dose of botulinum toxin that will
achieve the desired result to impede the development of im-
munogenicity.
Apraclonidine eyedrops are useful in the event of botulinum
toxin-related blepharoptosis.
Use a graduated approach to dermal ﬁ llers—consider starting
patients with shorter-duration ﬁ llers and advance to longer-
duration ﬁ llers once appropriate patient satisfaction has been
acknowledged.
Permanent ﬁ llers can lead to permanent problems.

Surgery and anesthesia are uniquely interdependent.
Each discipline cannot exist without the other. Improve-
ments by each interact for the beneﬁ t of the patient,
while the potential complications of each can negatively
impact the patient. Surgeons and anesthesia profes-
sionals must cooperate and communicate to maximize
patient safety through minimizing the likelihood of
complications.
In hospital settings, anesthesia is administered by
personnel trained in anesthesia: a physician anesthesi-
ologist, a nurse anesthetist, an anesthesia assistant, or a
team of an anesthesiologist with either of the other two.
However, this is not always the case in the setting of
sedation and analgesia, particularly outside traditional
hospital operating rooms. The surgeon will then have a
role in supervising the care given by the individual ad-
ministering the sedation. In some states, the surgeon
will also supervise the nurse anesthetist if an anesthesi-
ologist is not involved in the case. Regardless of the ar-
ray of practitioners, proper avoidance and management
of complications requires input from all participants.
Understanding, appreciation, and anticipation of risks
help to prevent untoward outcomes.

◆Outcome of Anesthesia Care
Anesthesia complications are any adverse, undesired
outcomes related to anesthesia care. As with all com-
plications of medical care, the primary focus should be
on prevention. Sometimes these outcomes cause direct
morbidity or mortality to the patient. At other times,
they aﬀ ect the patient indirectly by impeding the surgi-
cal procedure, such as intraoperative hypertension that
leads to excessive bleeding or inadequate relaxation
leading to patient movement at a critical delicate point
in the operation.
Over all, anesthesia care is remarkably safe. Due to the
lack of centralized statistics and consistent deﬁ nitions,
it is very diﬃ cult to determine an exact mortality rate
related solely to anesthesia. However, the risk of anes-
thesia catastrophe (death, permanent brain damage, or
intraoperative cardiac arrest) in healthy patients is van-
ishingly small, in the range of 1:150,000 to 1:300,000.1
When these catastrophes do occur, they usually involve
the coincidence of two or more deviations from nor-
mal circumstances at the same time and often include
unrecognized inadequate ventilation (from any of sev-
eral causes—including simple inattention), failures of
the oxygen supply, or, rarely, other equipment failures.
This is not to say that other critical incidents (such as
disconnection of the breathing circuit) are rare. These
still occur with some frequency, but they usually do not
cause adverse outcomes because the behaviors of the
anesthesia professional, augmented by the alarms and
warning signals from the safety monitoring equipment,
catch such developments very early in the evolution of
an event, allowing correct diagnosis and treatment long
before there is any real danger to the patient.
Insight about adverse outcomes unique to anesthesi-
ology can be found from the American Society of An-
esthesiologists Closed Claims Project. Starting in 1984,
many medical malpractice insurance companies were
persuaded to open their closed ﬁ les and allow conﬁ den-
tial examination of the litigation records. All these cases,
by deﬁ nition, involved adverse anesthesia outcomes.
They were examined for patterns of causes and eﬀ ects
regarding untoward clinical events, which were usually
severe and involved at least perceived damage that led
to lawsuits against anesthesiologists. A summary of the
positive impact of the project during its ﬁ rst 17 years2
reveals the extensive breadth of the ﬁ ndings.
One important initial ﬁ nding was that “respiratory
system adverse events” accounted for a signiﬁ cant frac-
tion of the claims, particularly lawsuits involving death
or brain damage.3 The main focus of the study was not
on the concept of preoperative predictors of adverse
anesthesia outcome as much as it was on the causation
of the adverse events. It was determined that failure to
monitor adequately was the main reason for the adverse
17
4
Anesthesia Complications
in Facial Plastic Surgery
John H. Eichhorn and Daniel T. Goulson

Complications in Facial Plastic Surgery
18
Premedication Prior to Surgery
Most premedications given today are anxiolytics, anal-
gesics, antiemetics, or medicines for prophylaxis against
aspiration of stomach contents. Anxiolytics (such as
midazolam) and especially narcotics (such as fentanyl)
may lead to depression of consciousness or ventilation,
which can lead to patient harm if it is not anticipated
and recognized quickly. Monitoring of hemoglobin satu-
ration with oxygen using pulse oximetry may help to
detect problems, but hemoglobin desaturation is a late
development in the downward spiral from excessive de-
pressant medication, so direct visual monitoring by per-
sonnel trained to detect hypoventilation (whether from
airway obstruction, CNS depression, or both) is likely to
be more helpful. Patients are at higher risk for ventilato-
ry depression if they take either anxiolytics or narcotics
chronically at home, because there can be an additive
eﬀ ect with similar medications that may be given on
the day of surgery. Extreme caution and hypervigilance
should be exercised in this situation.
Metoclopramide is sometimes given for both anti-
emesis and (because it is a pro-motility agent intended
to help empty the stomach) aspiration prophylaxis. Be-
cause it blocks post-synaptic dopaminergic receptors,
dystonic and other extrapyramidal reactions can be seen,
though occurring in less than 1% of patients.5 Patients
may also experience feelings of anxiety and agitation,
which occur more often when the drug is administered
as a rapid IV bolus as opposed to the recommended slow
infusion. Such adverse reactions can typically be treated
with diphenhydramine (25 or 50 mg, IV) or benztropine.
Other agents that have found some success in reducing
postoperative nausea and vomiting (PONV) include on-
dansetron, aprepitant, and Decadron.
Aspiration of acid stomach contents can be one of the
most serious complications of anesthesia care. A true
acid aspiration pneumonitis carries signiﬁ cant mor-
bidity and an appreciable mortality. Accordingly, it is
critical that patients observe the prescribed pre-op NPO
regime, the recommended precise details of which are
debated and are evolving.6,7 Many eﬀ orts can be made
to help minimize aspiration risks. Patients with known
gastroesophageal reﬂ ux disease (GERD) and/or hiatus
hernia, or even with a tendency to frequent “heartburn,”
may beneﬁ t from an attempt at reduced preoperative
stomach acid production with either an H-2 blocker
(such as famotidine) or a proton pump inhibitor (such as
omeprazole), metoclopromide as noted to promote gas-
tric emptying, and PO sodium citrate (Bicitra) to neu-
tralize any remaining stomach acid. Such a regime may
apply equally or even more so to patients scheduled for
sedation and analgesia who will not have a secured air-
way but who may become relaxed or nauseated enough
to regurgitate residual stomach contents. The gravity of
the potential complications is so great that this question
must be considered for every patient.
outcomes and that 93% of the preventable mishaps
would have been avoided by the correct application of
capnography and pulse oximetry together to help en-
sure appropriate ventilation and oxygenation.4
Traditional potential adverse outcomes that are caused
largely by anesthesia care and manifest within 24 to 48
hours of surgery are listed in Table 4.1. Some authors
might add severe bronchospasm, or airway burns, to
this list of anesthesia complications.

◆ Complications of Anesthetic
Medications
The practice of anesthesiology intimately involves the
use of medications. An unfortunate reality is that most
medications have some degree of side eﬀ ect, adverse
reactions, and unwanted interaction with other medi-
cations. One signiﬁ cant implication is that it is very im-
portant to understand and fully evaluate the patient’s
chronic medications because of the possibility of inter-
actions with anesthetic medications.
Table 4.1
Traditional Potential Adverse Outcomes of Anesthesia Care
Broken teeth from laryngoscopy
Corneal abrasion
Allergy to anesthetic medications
Unintended awareness during general anesthesia
Unplanned admission to the hospital following outpatient
surgery
Unplanned postoperative admission to an intensive care unit
Pneumonitis from aspiration of acid stomach contents
Emergency reintubation in the immediate postop period
Peripheral nerve injury
Neuraxial nerve injury, including stroke, with deﬁ cit
Unanticipated pulmonary edema
Malignant hyperthermia
Hypoxic brain injury
Myocardial infarction
Cardiac arrest
Death

4 Anesthesia Complications in Facial Plastic Surgery
19
Among local anesthetics, there appears to be a diﬀ er-
ence in their propensity to cause cardiac toxicity. Expe-
rience has shown that bupivicaine (Marcaine) toxicity is
the most likely to lead to cardiovascular collapse, which
is particularly diﬃ cult to treat. This ﬁ nding led to the
search for a safer long-acting local anesthetic.11 Analysis
of laboratory data suggests that cardiac toxicity is asso-
ciated with the dextro (R-) enantiomer of bupivacaine
and that the S-enantiomer is less troublesome. Ropi-
vacaine, which was released for use in 1996, is a pure
S-isomer that has less cardiotoxicity than bupivacaine.
It is more expensive than bupivacaine, but when large
volumes of local anesthetic are used with a high likeli-
hood of intravascular injection or signiﬁ cant absorption,
its greater safety justiﬁ es the increased cost.12
Maximum Dose of Local Anesthetics
Even when local anesthetics are administered by in-
ﬁ ltration into soft tissues, some is absorbed into the
bloodstream, and this absorption can, in excess quan-
tity, be toxic. Table 4.2 shows maximum recommended
inﬁ ltration doses of various local anesthetics.13
Local Anesthetic Allergy
Patients occasionally report “allergy” to local anesthetic
agents, but true allergy to local anesthetics is quite rare.
Ester local anesthetics, which produce metabolites relat-
ed to para-aminobenzoic acid (PABA), are signiﬁ cantly
more likely to lead to allergic reactions than amide local
anesthetics, which do not produce these metabolites.8
Local Anesthetic Toxicity and Allergy
Local anesthetics are drugs that produce reversible
blockade of the conduction of impulses along central
and peripheral nerve pathways by inhibiting passage of
sodium ions through ion-selective sodium channels in
nerve membranes. Removal of the local anesthetic by
redistribution or metabolism is followed by spontane-
ous and complete return of nerve conduction with no
evidence of structural damage to nerve ﬁ bers.8 Thus,
wary patients may be reassured that local anesthetics
do not cause permanent dysesthesia.
Systemic toxicity from a local anesthetic occurs when
there is an excess plasma concentration of the drug that
may manifest in the central nervous system or cardio-
vascular system. Accidental direct intravascular injec-
tion is the most common mechanism for producing such
an excess plasma concentration. Less often, excess plas-
ma concentration results from absorption of signiﬁ cant
amounts of the local anesthetic from the injection site.
Central Nervous System Toxicity
Nervous system toxicity manifests in a continuum,
depending on the plasma concentration of local anes-
thetic. The initial symptoms of local anesthetic toxicity
usually include numbness of the tongue and circum-
oral tissues. As the plasma concentration increases,
restlessness, vertigo, and tinnitus may result from
the local anesthetic crossing the blood-brain barrier.
Very high plasma concentrations produce tonic-clonic
seizures.
Treatment of local anesthetic-induced seizures con-
sists of ventilation with supplemental oxygen and, if in-
dicated, IV benzodiazepines (midazolam or diazepam).
Hyperventilation lowers the PaCO2, which decreases ce-
rebral blood ﬂ ow, thus resulting in a decreased delivery
of drug to the brain. This maneuver may be helpful in
reducing the plasma concentration in the face of a sei-
zure. Refractory seizures may require induction of gen-
eral anesthesia with a barbiturate.
Cardiovascular Toxicity
The reversible blockade of sodium channels from local
anesthetics can also block sodium channels in the heart,
which can lead to cardiac toxicity. Myocardial conduc-
tion and automaticity may become depressed when
enough of these channels become blocked. Increases
in local anesthetic blood levels may lead to varying de-
grees of heart block, the appearance of multi-focal ec-
topic beats, re-entrant arrhythmias, tachycardia, and,
ultimately, ventricular ﬁ brillation. Treatment is sup-
portive and includes oxygen, vasopressors, inotropes,
and anti-dysrhythmics if needed.9 Evidence is building
that infusing a 20% lipid emulsion may be helpful when
there is cardiac arrest due to bupivacaine toxicity.10
Table 4.2
Clinical Properties of Local Anesthetic Agents
Local Anesthetic Agent
Duration
of Action
(h)
Maximum
Safe Dosage
(mg/kg)
Lidocaine (plain)
1.5–2
4
Lidocaine (with epinephrine)
2–2.5
7
Bupivacaine (plain)
3–6
1–2
Bupivacaine (with epinephrine)
6–10
2–3
Mepivacaine
2.5–3
7
Ropivacaine
6–10
1–2.5
Tetracaine
1–3
1–2
Cocaine
0.75–3
3–4
Adapted from Ahlstrom KK, Frodel JL. Local Anesthetics for Facial
Plastic Procedures. Otolaryngologic Clinics of North America;
2002;35(1):29–53.

Complications in Facial Plastic Surgery
20
no analgesia and relatively little ventilatory or cardiovas-
cular depression in truly conservative doses. Narcotics
are analgesics that cause respiratory and cardiovascular
depression, but only small amounts of anxiolysis and no
appreciable amnesia. Propofol has very little analgesic
eﬀ ect, but produces anxiolysis and unconsciousness.
Therefore, if the patient is having a procedure where ex-
cellent analgesia can reliably be achieved with local an-
esthesia but the patient is anxious, then sedation with
only a benzodiazepine would be adequate and a narcotic
would be unnecessary.
The deﬁ nition of therapeutic index is the ratio be-
tween the toxic dose and the eﬀ ective therapeutic dose
of a drug, and it is used as a measure of the relative
safety of the drug. Drugs with a small, or narrow, thera-
peutic index have a very little diﬀ erence between the
plasma concentrations that produce the desired eﬀ ect
and toxicity. The same concept can be applied in situ-
ations when the concern is not overt toxicity, but un-
desired side eﬀ ects. This is the case with medications
used for IV sedation. Many of these drugs, most notably
propofol and remifentanil, have a very narrow thera-
peutic index related to ventilatory depression. This re-
quires that these speciﬁ c medications be titrated very
carefully and that patients are monitored very closely
for adequate ventilation and oxygenation.
Table 4.3 shows the ester and amide classiﬁ cation of
local anesthetics, as well as other items of comparative
pharmacology. Because PABA is usually the culprit in
true allergy, there is often cross-sensitivity within the
ester classiﬁ cation. (For example, a patient allergic to
tetracaine will also likely have an allergic reaction to
procaine.)
Sometimes, allergies that are attributed to local an-
esthetics are actually caused by preservatives, such as
methylparaben, used in the preparation of local anes-
thetic agents. These compounds are structurally related
to PABA. Patients with allergies to preservatives can
safely receive preservative-free local anesthetics.
Another common reason for “allergy” to local anes-
thetics is a normal response to epinephrine. Epinephrine
is often added to local anesthetics to provide vasocon-
striction, which slows the systemic absorption of the lo-
cal anesthetic and therefore prolongs the action of the
drug. Intravascular absorption of epinephrine can lead
to tachycardia, palpitations, ﬂ ushing, and hypertension,
all of which the patient may incorrectly interpret as an
allergic reaction, usually during dental work. Therefore,
when a patient reports a drug allergy, it is important
to obtain a detailed history in an attempt to determine
exactly what took place during the incident and guide
subsequent therapy accordingly. It is extremely unlikely
that a patient is truly allergic to an amide local anes-
thetic. If the reaction did not include any rash, hives,
swelling, or bronchospasm but does describe a typical
response to epinephrine, it may be reasonable simply to
proceed slowly with an amide local anesthetic (knowing
that appropriate anaphylaxis treatment is available, as
it always must be for every case). On the other hand, if
there is genuine doubt, it is reasonable to postpone any
use of local anesthetic and refer the patient to an aller-
gist for testing.
Intravenous Sedation
Sedation is typically produced through the use of any
number of intravenous medications, either alone or in
combination. The classic combination is a benzodiaz-
epine, such as midazolam, and a narcotic, such as fen-
tanyl (which has replaced meperidine in many practices
because repeated doses of meperidine are associated
with the potential for seizures). Though midazolam is
used commonly as the benzodiazepine of choice, several
diﬀ erent narcotics are often used, including the ultra-
potent synthetic narcotics fentanyl and remifentanil. In
the past 20 years, the hypnotic drug propofol has been
introduced into practice, either alone or in combina-
tion with other medications. Ketamine, a dissociative
hypnotic drug, has also been used as a non-narcotic
sedative.
The desired eﬀ ect of IV sedation varies with the par-
ticular situation, and this drives the choice of drugs.
Benzodiazepines produce anxiolysis and amnesia, but
Table 4.3
Comparative Pharmacology of Local Anesthetics
Classiﬁ cation
Potency
Onset
Duration after
inﬁ ltration
(mins)
Esters
Procaine
1
Slow
45–60
Chloroprocaine
4
Rapid
30–45
Tetracaine
16
Slow
60–180
Amides
Lidocaine
1
Rapid
60–120
Etidocaine
4
Slow
240–480
Prilocaine
1
Slow
60–120
Mepivacaine
1
Slow
90–180
Bupivacaine
4
Slow
240–480
Ropivacaine
4
Slow
240–480
Adapted from Stoelting RK. Pharmacology and Physiology in Anes-
thetic Practice. 3rd ed. Philadelphia: Lippincott-Raven;1999.

4 Anesthesia Complications in Facial Plastic Surgery
21
component of the anesthetic. As with all drugs, many of
these anesthetic agents have important side eﬀ ects. In
adults, anesthesia is typically induced by either propofol
or (rarely) sodium thiopental. Both of these induction
agents are vasodilators, and sodium thiopental is a myo-
cardial depressant as well. Some degree of hypotension
is common after administration of these drugs.
After induction, anesthesia is often maintained by
one of the volatile anesthetic agents. These drugs, usu-
ally desﬂ urane and sevoﬂ urane (or possibly isoﬂ urane)
in facial plastic surgery, can also cause vasodilation and
produce hypotension. They have diﬀ ering eﬀ ects on the
bronchial tree, with sevoﬂ urane and isoﬂ urane leading
to bronchodilation and desﬂ urane causing bronchocon-
striction. Desﬂ urane is often avoided in patients with
reactive airway disease because of its tendency to irri-
tate the airways.
Administration of intravenous ﬂ uids, sometimes in
signiﬁ cant quantities, is often required to counteract the
hypotension from vasodilation caused by these drugs.
Routinely in healthy patients, the kidneys eventually
eliminate this extra ﬂ uid, and it is of no consequence. In
some patients, this ﬂ uid can lead to tissue edema. This
can be signiﬁ cant in facial procedures, so the need for
the maintenance of blood pressure must be balanced
against the harm of swelling, and this is an appropriate
point for preoperative discussion between the surgeon
and the anesthesia professional(s).
Of the muscle relaxants in common use today, succi-
nylcholine is the one that may potentially produce un-
toward side eﬀ ects (beyond the expected consequence
of apnea from all the muscle relaxants). Succinylcholine
can cause a transient increase in plasma potassium lev-
els, typically on the order of 0.5 mEq/l.17 This increase
may be signiﬁ cant in patients with already abnormally
high potassium levels, such as in renal failure. In cer-
tain scenarios, such as after burns or crush injuries, the
potassium increase caused by succinylcholine may be
much more than 0.5 mEq/l. Succinylcholine is rapidly
hydrolyzed by plasma pseudocholinesterase enzymes,
and in rare cases patients have an abnormality (quantity
or quality) of these enzymes, resulting in a duration of
action of the drug of hours instead of minutes. Succinyl-
choline is also one of a handful of drugs that can trigger
malignant hyperthermia (see below). However, despite
its potential problems, succinylcholine is the only mus-
cle relaxant currently available with a rapid onset and
typically ultrashort duration of action, and this makes it
the drug of choice in some situations, particularly facili-
tating intubation for short cases or with patients having
potentially diﬃ cult airways.
Malignant Hyperthermia
Malignant hyperthermia (MH) is an anesthetic-related
disorder of skeletal muscle metabolism.18 It is an in-
herited condition that is triggered on exposure to ei-
Making the use of IV sedation even more diﬃ cult is
the remarkable synergy that exists among many of
these drugs. A dose of midazolam that produces perfect
anxiolysis alone can lead to respiratory depression if a
small analgesic dose of narcotic is added. Again, titra-
tion and monitoring are of utmost importance. When a
patient moves or moans near the end of a facial plastic
surgery case being done under IV sedation, the almost-
reﬂ ex response of administering one last dose of 0.5
mg midazolam, 25 micrograms of fentanyl, or 12.5 mg
meperidine could be enough to cause dangerous ven-
tilatory insuﬃ ciency (central depression and/or airway
obstruction from relaxation).
Propofol is an extreme example of this quandary be-
cause the same drug can produce both excellent con-
scious sedation and deep general anesthesia with an
electrically silent EEG, just by varying the dose. The avail-
ability and use of this drug by non-anesthesiologists was
one of the primary motivators for the American Society
of Anesthesiologists to produce practice guidelines for
sedation and analgesia for non-anesthesiologists.14 This
document reviews the continuum between minimal se-
dation, moderate sedation, deep sedation, and general
anesthesia and provides deﬁ nitions. Recommendations
in the guidelines include items related to patient prepa-
ration, patient monitoring, training of personnel, avail-
ability of emergency equipment, use of supplemental
oxygen, titration of medications, and recovery care.
Facial plastic surgeons directing the administration of
propofol for sedation should review and actively apply
these guidelines.
Because of the narrow therapeutic index of many of
the medications that are used for IV sedation, it is ex-
tremely diﬃ cult to achieve a level of “conscious” seda-
tion, where the patient has analgesia and sedation, but
is still able to respond to commands (a central deﬁ nition
of “conscious” sedation). When patients accidentally are
put in deeper levels of sedation, it is critical that prac-
titioners either be able to provide life support, reverse
the sedation, or both. There have been many instances
of failure to rescue patients from deep sedation, which
often results in patient harm.15
Because there have been incidences of major morbid-
ity and mortality that have been publicized, concerns
about proper sedation care have appeared in the lay
press. Patients are becoming more aware of potential
pitfalls of sedation for procedures and are demand-
ing that guidelines for properly trained personnel and
equipment are followed.16
General Anesthesia
General anesthesia refers to a state of unconsciousness,
amnesia, analgesia, and relaxation that permits calm
surgery. This state is often produced by the administra-
tion of several diﬀ erent drugs to the patient by the anes-
thesia professional, each of which focuses on a diﬀ erent

Complications in Facial Plastic Surgery
22
ASA Physical Status Classiﬁ cation
The American Society of Anesthesiologists (ASA) Physi-
cal Status (PS) classiﬁ cation (Table 4.4) was developed
in 1941 with the intent of facilitating studies of patients
undergoing anesthesia and surgery. The system was
enhanced in 1961 and acquired its modern form. It has
provided a basis for communication among anesthesia
and non-anesthesia professionals by describing the acu-
ity and the likely anesthetic challenge of a patient and
facilitates the most logical assignment of personnel and
resources for a given case.
In recent years, extensive discussion of the correlation
of the ASA PS classiﬁ cation with surgical risk factors in
the database of the National Surgical Quality Improve-
ment Program (NSQIP) has taken place. In a random
sample of almost 6000 major surgical procedures, the
PS classiﬁ cation was found to be a strong predictor of
surgical outcomes. As shown in Table 4.5, morbidity
and mortality rose with increases in the PS classiﬁ ca-
tion. The NSQIP database was shown to correlate with
and (in some circumstances) predict surgical outcome,
thus validating the ASA PS classiﬁ cation.22
Cardiovascular
Predictors of adverse surgical and anesthesia outcomes
suggest that cardiac risk is the most prominent con-
sideration. Extensive studies and recommendations
have been published on this issue.23 The greatest risks
for perioperative cardiac complications include the
usual suspects: recent myocardial infarction, unstable
or severe angina, decompensated CHF, signiﬁ cant dys-
rhythmias, heart block, and untreated valve disease. In-
traoperative risk is highest for the most invasive surgery
and prolonged surgery with major ﬂ uid shifts. Many
risk-scoring schemes for predicting postoperative car-
diac complications exist, one being the Revised Cardiac
ther volatile anesthetics, succinylcholine, or both. Its
importance to plastic surgeons assessing patients has
been discussed.19 When the increased metabolic state
is triggered, signs include severe sudden hypercarbia,
tachycardia, muscle rigidity, acidosis, and eventually
hyperthermia (although this is a late development, so if
there is a question, waiting to see the temperature rise
allows the syndrome to advance to a very dangerous
stage). The very dramatic initial sharp rise in end-tidal
CO2 with signiﬁ cant tachycardia should provoke a pre-
sumptive diagnosis and invoke immediate treatment.
Since MH is an inherited disease, susceptibility to it
can often be predicted by taking a careful family history.
If a patient is determined or suspected to be suscep-
tible, a perioperative episode of MH can almost always
be avoided by limiting exposure to triggering agents.
Stated diﬀ erently, if general anesthesia is necessary,
then propofol, which does not trigger MH, can be used
for both induction and maintenance of anesthesia by in-
travenous infusion.
If MH does occur, the initial treatment is straight-
forward: call for help and dantrolene; discontinue any
possible triggering agent and hyperventilate with 100%
oxygen; administer an initial dose of 2.5 mg/kg of dan-
trolene and also treat the conﬁ rmed blood-gas meta-
bolic acidosis with IV bicarbonate; cool actively with
iced ﬂ uids IV, in cavities, and to the skin; place a large IV
and a urinary catheter. The critical component of treat-
ment is the dantrolene, a skeletal muscle relaxant that
may require repeated doses in sequence. Because of this,
dantrolene must be stocked in every facility that uses
any of the possible triggering medications, and a mini-
mum of 36 vials is recommended. A patient suspected
of having the disease in an oﬃ ce or ambulatory surgery
center must be transferred to a hospital as soon as pos-
sible. Education and communication about this disorder
is provided by the Malignant Hyperthermia Association
of the US (MHAUS, ). The MH Hotline
(1–800-MHHYPER, or 1–800–644–9737) provides tele-
phone service to medical professionals for emergency
consultation.

◆ Patient and Anesthetic Technique
Selection and Evaluation for Facial
Plastic Surgery
Patient Factors That May Lead to Anesthetic
Complications
The best way to manage complications is to avoid them.
This approach helps to create an environment that pro-
motes patient safety, which is in the forefront of medical
practice today.20 Anesthesiologists and other physicians
have been interested in determining which patient-spe-
ciﬁ c factors predict postoperative complications in that
patient.21
Table 4.4
American Society of Anesthesiologists Physical Status
Classiﬁ cation
PS I - A normal healthy patient
PS II - A patient with mild systemic disease
PS III - A patient with severe systemic disease
PS IV - A patient with severe systemic disease that is a constant
threat to life
PS V - A moribund patient who is not expected to survive with
or without the operation
PS VI - A declared brain-dead patient whose organs are being
removed for donor purposes

4 Anesthesia Complications in Facial Plastic Surgery
23
tions are chronic obstructive pulmonary disease, age
older than 60 years, ASA class of II or greater, function-
ally dependent, and congestive heart failure. Preexist-
ing airway pathology, from diseased teeth to congenital
or traumatic anatomic abnormalities that may prevent
easy intubation, can predispose a patient to potential
adverse outcomes, although patients whose airways are
predicted to be easy to manage26 may occasionally face
the greatest danger due to the lack of recognition and
appropriate preparation. Airway issues remain among
the thorniest problems still unsolved in modern anes-
thesia practice,27 and appeals for improved equipment,
techniques, and management strategies persist.
Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) is a speciﬁ c condition
with several relevant risks. Though this disease increas-
es the risk for airway management diﬃ culties in the
immediate postoperative period, its inﬂ uence on post-
operative pulmonary complication rates has not been
fully investigated, with only one study evaluating the
risks.28 There were nonstatistically signiﬁ cant trends to-
ward higher rates of reintubation, hypercapnia, and hy-
poxemia for patients with obstructive sleep apnea.
The ASA has published guidelines that focus on the
perioperative management of patients with OSA, who
may be at increased risk for perioperative morbidity
and mortality because of potential diﬃ culty in main-
taining a patent airway.29 Further, these issues can easily
be compounded in patients during or after facial plastic
or reconstructive surgery. One challenge of dealing with
OSA is that the vast majority of patients with this condi-
tion have not been formally diagnosed. The guidelines
include risk factors for OSA, along with the recommen-
dation that if patients are found to have a high risk, they
should be treated as if they have the disease. Patients
with OSA should receive extended and more intense
monitoring for adverse ventilatory events both during
and after facial plastic surgery.
Choice of Anesthetic Technique
Many facial plastic surgery procedures can be done with
either general anesthesia (GA) or monitored anesthesia
care (MAC). The surgeon often indicates a preference
to the anesthesia professional(s). General anesthesia is
typically produced and maintained with either intrave-
nous or inhalational medications and usually depresses
ventilation enough that some type of artiﬁ cial support
is necessary. That support can be provided either with
an endotracheal tube or a laryngeal mask airway (LMA).
From the surgeon’s perspective, the advantages of GA
are that the patient is completely unconscious, insen-
sate, and still. However, several risks of GA should be
considered. When combined with surgery, GA can re-
sult in physiologic stress for the patient that can upset
Risk Index.24 As shown in Table 4.6, six factors were
found to predict cardiac complications. When only one
of these factors is present, there is a 0.9% chance of a
major cardiac complication; two increase the chance to
7% and three to 11%.
Pulmonary
The factors predicting pulmonary complications have
not been studied to the same degree as cardiac risk,
but the American College of Physicians has published
relevant guidelines.25 Formulated by use of systematic
review techniques, these guidelines indicate that signiﬁ -
cant risk factors for postoperative pulmonary complica-
Table 4.5
Perioperative Mortality Rate and Morbidity Rate
(All Causes) by ASA PS Level
ASA PS Level
30-Day Mortality
Rate (%)
30-Day Morbidity
Rate (%)
I
0.0 ± 0.0
1.7 ± 0.4
II
0.2 ± 0.1
4.0 ± 0.4
III
2.2 ± 0.4
11.3 ± 0.8
IV
15.2 ± 2.4
31.7 ± 3.1
V
70.0 ± 10.5
40.0 ± 11.2
Adapted from Davenport DL, Bowe EA, Henderson WG, et al. Na-
tional Surgical Quality Improvement Program (NSQIP) risk factors can
be used to validate American Society of Anesthesiologists Physical
Status Classiﬁ cation (ASA PS) levels. Ann Surg 2006;243:636–641,
discussion 641–644.
Table 4.6
Independent Correlates of Major Cardiac Complications
Revised Cardiac Risk Index
1. High-risk type of surgery
2. Ischemic heart disease
3. History of congestive heart failure
4. History of cerebrovascular disease
5. Insulin therapy for diabetes
6. Preoperative serum creatinine >2.0 mg/dL
Adapted from Lee TH, Marcantonio ER, Mangione CM, et al. Derivation
and prospective validation of a simple index for prediction of cardiac
risk of major noncardiac surgery. Circulation 1999;100:1043–1049.

Complications in Facial Plastic Surgery
24
minister the sedative or analgesic medications is un-
known. On the surface, it might be proposed that an
anesthesiologist is most medically qualiﬁ ed to do so,
but this choice is also the most expensive. On the other
end of the spectrum, the operating surgeon may order
that the sedative medications be administered by a
registered nurse, under the impression that the seda-
tion plays only a minor role in the care of the patient
and that this method serves to minimize cost and max-
imize convenience.
While complications during sedation have been re-
ported when patients have been cared for by all dif-
ferent types of practitioners,30 there is consensus that
sedation should be provided by someone who is trained
to monitor the patient adequately and who is not partic-
ipating in the surgical procedure.14 Extensive guidelines
and statements by the American College of Surgeons
and the American Society of Anesthesiologists on the
critical issues of the depth of sedation and the appro-
priateness of involved personnel have been published
(and undoubtedly would have medical-legal implica-
tions in the event of malpractice litigation).36 In cases
of moderate or deep sedation, the person administering
sedation should also be able to rescue the patient from
excess sedation, provide advanced life support skills,
and establish an emergency airway. This approach helps
to avoid complications by directing maximum attention
speciﬁ cally to the patient’s sedation and analgesia, in
particular the monitoring of ventilation, oxygenation,
and cardiovascular function.

◆ Anesthesia Considerations and
Complications Speciﬁ c to Facial
Plastic Surgery
Considerations Relative to the Location and Other
Characteristics of the Surgery
Duration of Surgery
The duration of the procedure is one factor that has been
shown to have a positive correlation with incidence of
postoperative complications.7,37 Lengthy procedures
with local anesthesia and sedation or monitored anes-
thesia care are limited by the patient’s ability to hold
still on the table without requiring so much sedation as
to be at risk for dangerous hypoventilation (mechanical
airway obstruction, CNS depression, or both). Lengthy
procedures under general anesthesia are more likely to
lead to postoperative atelectasis, nausea and vomiting,
and (in the setting of a planned ambulatory procedure)
unplanned hospital admission. This has led some to rec-
ommend that only cases of shorter duration should be
considered for an oﬃ ce-based procedure. The time limit
for what would be considered a shorter case is subject to
debate and varies among practitioners. Experience over
homeostasis and result in cardiovascular or cerebrovas-
cular complications. Since ventilation and oxygenation
must be maintained artiﬁ cially, GA also introduces the
opportunity for complications related to management
errors or simple inattention.
These potential complications and the overall degree
of invasiveness have led some surgeons to attempt to
avoid GA whenever possible. MAC typically involves
the administration of some degree of sedation and
analgesia by an anesthesiologist or nurse anesthetist,
combined with local anesthesia administered by the
surgeon. Because it is intended that the patient main-
tain spontaneous ventilation, it is tempting to think that
this anesthetic technique is inherently safer. However,
there are no randomized controlled trials that demon-
strate a favorable diﬀ erence in complication rates be-
tween general anesthesia and MAC, and there certainly
have been reports of signiﬁ cant morbidity and mortal-
ity during and after MAC.15,30 In the data of the closed
claims project of the ASA, claims associated with MAC
showed a high severity of patient injury and a liability
proﬁ le similar to claims associated with general anes-
thesia.31 In fact, many anesthesia professionals believe
there is a greater risk with MAC than with GA for rela-
tively extensive procedures, particularly those involving
the face, head, and neck because the airway is usually
not immediately accessible (as would need to be for a
resuscitative jaw thrust or insertion of an oral airway
device to help overcome a patient’s obstructed airway
following an additional dose of IV sedation medication).
Therefore, it is extremely important to maintain vigilant
monitoring and management of patients under MAC
that is at least equal to that with GA.
Another alternative to GA is involved in tumescent
liposuction. This technique includes the subcutaneous
infusion of signiﬁ cant volumes of a solution contain-
ing lidocaine, followed by the aspiration of fat through
microcannulas. It is attractive because it is reported to
provide excellent anesthesia, often without the need for
systemic sedation or analgesia. Though tumescent lipo-
suction has been performed thousands of times with-
out problems,32,33 within the last two decades, there
have been reports of morbidity and mortality after this
technique was used.34 In one study, Rao describes four
deaths, three of which were probably related to lido-
caine toxicity and one related to ﬂ uid overload. Guide-
lines now exist for dosage limits for local anesthetics
and volume limits for wetting solutions;7,35 their imple-
mentation should reduce risk but cannot eliminate it.
Qualiﬁ cations of Practitioner Providing Sedation
Many diﬀ erent personnel models have been used at
one time or another for providing sedation care to pa-
tients who are undergoing painful procedures. Though
these diﬀ erent models have been discussed a great
deal, which type of practitioner is best suited to ad-

4 Anesthesia Complications in Facial Plastic Surgery
25
dissipating into the room air. There have been sporadic
reports of ﬁ re in the literature over the years.39 There
has been an increased awareness of the risk of ﬁ res, es-
pecially by accrediting bodies.40 The American Society
of Anesthesiologists has published a practice advisory
providing detailed recommendations on avoiding op-
erating room ﬁ res41 (which, again, could have medical-
legal implications); in addition, the Anesthesia Patient
Safety Foundation has issued an extremely popular
instructional video with illustrative scenarios (http://
).
Several strategies can be employed to reduce the risk
of ﬁ re. When monopolar electrocautery is used, open
delivery of supplemental oxygen should be avoided if at
all possible. The reﬂ ex administration of oxygen when-
ever IV sedation is employed often is unnecessary and
may actually be a disservice because it is likely to create
a false sense of security if there is a lack of appreciation
of the diﬀ erence between ventilation and oxygenation.
The supplemental O2 will delay the appearance of desat-
uration on the pulse oximeter when extremely danger-
ous hypoventilation is evolving. In the rare case when
supplemental oxygen is deﬁ nitely required due to, for
example, severe pulmonary disease and monopolar
electrocautery is used near the oxygen, the oxygen ﬂ ow
rate delivered by either nasal cannula or mask should be
reduced to the absolutely lowest level possible for that
patient. The use of “open face” draping techniques or an
eﬀ ective venting scheme may prevent oxygen pooling.
Lastly, the avoidance of alcohol-based prep solutions
may eliminate one combustion fuel source. The ECRI In-
stitute oﬀ ers a large wall poster (
Documents/Surgical_Fire_Poster(2009).pdf) on preven-
tion of surgical ﬁ res.
Capnographic Monitoring
As noted, the ASA Closed Claims Project revealed that
many malpractice claims involved adverse respiratory
events (inadequate ventilation) and that a failure to
monitor the patient adequately was a contributing fac-
tor in most of those cases. Facial plastic surgery, particu-
larly without a mechanically secured airway, has among
the greatest risks for intraoperative ventilatory insuﬃ -
ciency. The ASA standards for basic intraoperative mon-
itoring require that capnography be employed to verify
correct endotracheal tube placement and then contin-
ued throughout the general anesthetic. Further, dur-
ing MAC, observation of ventilation qualitative clinical
signs or capnography (which can be accomplished with
certain nasal cannulae, but these may be in the surgi-
cal ﬁ eld) must be used.42 The danger of hypoventilation
(both CNS depression and airway obstruction) during
MAC cannot be stressed enough—it is one of the great-
est risks during many of the most common facial plastic
surgical procedures and has appeared in the past to be
frequently underappreciated by the involved surgeons.
time with a given team in a given setting often provides
guidance as to a reasonable maximum.
Lengthy cases may also lead to problems with pa-
tient positioning and injuries associated with position-
ing issues.38 Therefore, when a long surgical procedure
is anticipated in any setting, great care should be given
to position the patient so that there is no traction on
nerves and minimal pressure on points of contact be-
tween the patient and the surgical environment.
Airway Management
Management of the airway is of critical importance to
the patient and of utmost concern to the anesthesia pro-
fessional. Several issues, such as distorted airway anato-
my and intraoperative access to the airway, are relevant
in both major and minor facial plastic and reconstruc-
tive cases.
In large facial reconstruction cases, the airway anatomy
is often abnormal because of the pathology. When gen-
eral anesthesia is induced, the abnormality may lead to
the need for advanced airway techniques, such as ﬂ exible
ﬁ beroptic laryngoscopy. If MAC is being considered when
the airway anatomy is abnormal, many anesthesiologists
will prefer to use general anesthesia with a secured air-
way from the outset, rather than take the risk of losing
control in the middle of the procedure if the patient de-
velops airway obstruction. If the airway is extremely dis-
torted or there is a high likelihood of postoperative upper
airway obstruction, doing a tracheostomy before starting
the planned surgical procedure should be considered.
Since in facial cases the surgical procedure is in close
proximity to the airway, both the surgeon and the anes-
thesiologist should be aware that they must share the
same space. The worst consequence of inattention to
this fact occurs when (during surgical manipulation) the
endotracheal tube becomes dislodged from the trachea
in the middle of a case, and the problem goes unrecog-
nized until impairment of ventilation and oxygenation
raises the alarm. Then there is precious little time to
restore the airway before the patient faces injury. Ob-
viously, careful planning, open communication (before
and during the case), and rigorous vigilance should help
avoid such incidents.
Pitfalls of Monitored Anesthesia Care
Supplemental Oxygen and Fire
Since oxygen supports combustion, the use of monopo-
lar electrocautery near high concentrations of oxygen
can produce a risk of ﬁ re. This is the scenario in some
facial cases done under sedation where there has been
ﬁ re, often involving ignition of cloth or paper drapes.
Supplemental oxygen administered by a nasal cannula
or plastic face mask may accumulate near the surgical
site if the drape conﬁ guration prevents the oxygen from

Complications in Facial Plastic Surgery
26
References
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and related severe injury through safety monitoring. Anesthe-
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◆ Immediate Postoperative Recovery
from Facial Plastic Surgery
Patients receiving anesthesia for any type of surgery
need appropriate facilities and personnel for immediate
postoperative recovery. This concept was highlighted
when surgical procedures began to be done commonly
in an oﬃ ce setting, because recovery was not done in
a typical postanesthesia care unit (PACU) equivalent to
that found in a hospital. In oﬃ ces, the anesthesia pro-
vider also is often occupied with a subsequent case or
simply leaves and thus is not available to assist with
postoperative problems. In the early days of oﬃ ce-
based surgery, patients sometimes recovered in a back
hallway, attended by non-clinical oﬃ ce staﬀ if at all. Not
surprisingly, anecdotes abound about patient deaths in
such scenarios.43
Guidelines for oﬃ ce-based surgery from the Ameri-
can College of Surgeons and the American Society of
Anesthesiologists are cited above.36 In addition, there
are three primary accrediting bodies involved with am-
bulatory surgery. They are the Joint Commission for Ac-
creditation of Healthcare Organizations (JCAHO), the
Accreditation Association for Ambulatory Health Care
(AAAHC), and the American Association for Accredita-
tion of Ambulatory Surgical Facilities (AAAASF). All
these accrediting organizations have standards for fa-
cilities, equipment, and personnel necessary for postan-
esthesia recovery. All facilities where moderate sedation
through general anesthesia is provided will reduce the
risk of untoward complications during the recovery
phase if they observe the standards of at least one of
these organizations. Some plastic surgeons with opera-
tories in their oﬃ ces or oﬃ ce buildings have voluntarily
sought formal accreditation to help maximize the safety
of their patients, particularly in the immediate postop-
erative recovery period. Malpractice insurance carri-
ers may oﬀ er premium discounts for plastic surgeons
whose oﬃ ce-based facilities are formally accredited.
Organizations such as the American Academy of Facial
Plastic and Reconstructive Surgery and the American
Society of Plastic Surgery have proactively linked their
membership to the performance of surgery only in duly
accredited facilities, thereby reducing the risks for their
membership’s patients undergoing surgery.

◆Conclusion
The anesthesia care associated with facial plastic and re-
constructive surgical cases is often underappreciated as
a source of potential danger. Awareness of and attention
to all of the points presented above will facilitate maxi-
mum eﬀ orts by all involved to help prevent complica-
tions and adverse anesthesia outcomes.
PEARLS OF WISDOM
The risk of overt catastrophe in healthy patients caused
solely by anesthesia care is probably as low as 1:150,000 to
1:300,000, and this remarkable degree of safety is a testament
to the recent improvements in anesthesia care.
Respiratory system adverse events (usually inadequate ventila-
tion) account for a signiﬁ cant majority of anesthesia complica-
tions—and even more so in facial plastic surgery due to airway
challenges and the signiﬁ cant danger of dangerous hypoventi-
lation during monitored anesthesia care.
Many anesthesia medications have side eﬀ ects that can lead to
untoward events in the absence of careful planning, execution,
and—above all—monitoring.
Local anesthetic toxicity can lead to CNS and cardiovascular
complications. Maximum dose guidelines should be consid-
ered, particularly in tumescent liposuction.
Malignant hyperthermia, though rare, is a serious threat. Dan-
trolene, the antidote, should be stocked in every facility that
uses general anesthesia.
The ASA guidelines for sedation and analgesia by nonanesthe-
siologists are extensive, valuable, and likely have medical-legal
implications, and they have been referenced by many profes-
sional and accrediting bodies.
Head and neck surgical ﬁ eld ﬁ res from the use of monopolar
electrocautery while open supplemental oxygen is adminis-
tered are a signiﬁ cant risk that can be reduced, particularly
with attention to readily available valuable instructional
materials.
The immediate postoperative recovery period can be an even
greater danger to the facial plastic surgery patient than the
surgical anesthetic, particularly in the oﬃ ce setting. The ACS
and ASA have extensive guidelines for conduct of oﬃ ce-based
surgery.

4 Anesthesia Complications in Facial Plastic Surgery
27
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The use of local and regional ﬂ ap reconstruction in the
repair of facial defects is a mainstay of facial plastic and
reconstructive surgery. The surgeon has various options
available when assessing treatment of a soft-tissue de-
fect. Each must be considered in the context of multiple
factors, such as knowledge of the anatomy, vascular sup-
ply, and tissue quality available. The surgeon is required
to select a course of action tailored to the individual that
may include healing by secondary intent, primary clo-
sure, skin grafts, local and regional ﬂ aps, distant ﬂ aps,
and free tissue transfer.
Each patient should be assessed in terms of age, race,
gender, occupation, nutrition, prior irradiation, skin
type, habits, and general health. Cosmetic success and
survival of a local or regional ﬂ ap depend on considering
all these variables. The appropriate surgical approach
must be based on both the distinctive characteristics of
the defect and the multiple unique factors presented by
each patient. The surgeon should strive to satisfy the pa-
tient’s reasonable expectations and goals, understand-
ing that these goals may diﬀ er greatly from patient to
patient, based on the individual’s priorities, age, gender,
and health.
No precise statistics regarding complication rates are
available, but adverse outcomes involving locoregional
ﬂ aps can best be avoided by meticulous preoperative
planning, a frank discussion with the patient about the
relative risks and beneﬁ ts associated with each recon-
structive approach, and sound technique. Before pro-
ceeding with treatment, the surgeon must fully evaluate
the dynamic spectrum of economic, psychosocial, and
general health issues, coupled with the reconstructive
dilemma each patient presents. The simplest approach
to repair is not always the best choice for the patient,
as sometimes a more complex approach will result in a
better cosmetic and functional result.
Sometimes primary closure is simple and eﬀ ective.
Healing by secondary intent is an excellent option for
small defects involving concave skin surfaces, such as
the medial canthus, temple, and occasionally the nasal
alar groove.1 Yet healing by secondary intent necessi-
tates a long period of wound care, which some patients
may not ﬁ nd acceptable. Conversely, wounds involv-
ing convex skin surfaces tend to heal poorly by sec-
ondary intent and are therefore more complex in their
management.
Locoregional ﬂ aps typically provide excellent skin col-
or and texture match, and they may be the best option
when primary closure and secondary intent closure are
not the best options. Reconstruction using locoregion-
al ﬂ aps can commonly be performed in a single stage,
and the donor sites can be closed primarily with little
morbidity.
Locoregional ﬂ ap complications can stem from poor
preoperative planning, infection, hematoma, or pa-
tient-speciﬁ c factors that compromise the vascularity
of the tissue or the healing of the scars. The choice of
an appropriate ﬂ ap to close a speciﬁ c defect is complex
and is not the point of this chapter. One is referred to
other textbooks on reconstruction for discussion of
ﬂ ap choices. Yet, one must understand that surgery
starts with the preoperative planning. Incisions have to
be planned parallel to relaxed skin tension lines, in aes-
thetic unit and subunit boundaries, or in the midline of
the face. An undersized ﬂ ap can result in distortion of
critical anatomic structures, causing ectropion, alar re-
traction, or retraction of other surrounding structures.
Deep wounds must be reconstructed with both ade-
quate structural support to overcome scar contracture
and adequate bulk to ﬁ ll the defect, but not so much
bulk as to cause a contour deformity. Deep layer clo-
sure is critical to decrease the dead space where blood
or scar tissue can accumulate, as well as to decrease
the tension on the skin closure so that wounds heal
with optimal scars. Although most complications can
be avoided, others are simply the result of indiscrimi-
nate odds. This chapter will focus on the complications
of locoregional ﬂ aps, ways to decrease the likelihood
of a complication, and management in the event of a
complication.
29
5
Complications Involving Locoregional
Flap Reconstruction of Facial Defects
David A. Sherris and Paul R. Young

Complications in Facial Plastic Surgery
30
Random ﬂ aps (e.g., bilobed, note, z-plasty) are the
most commonly used in local ﬂ ap repair of facial defects.
The vascular supply to random ﬂ aps, which consist of
skin and subcutaneous fat, arises mainly from multiple
musculocutaneous arteries from the subdermal plexus
at the ﬂ ap’s anatomic base. Therefore the appropriate
plane of dissection is at the level of the subcutaneous
fat. Axial ﬂ aps derive their blood supply from named
direct cutaneous arteries. Therefore, axial ﬂ aps allow
for greater length and reliability, with less concern for
width or a delay procedure.6 Surgically, the plane of dis-
section is deeper to incorporate fascia and must align
along a distinct septocutaneous vessel. Examples of ax-
ial ﬂ aps include the paramedian forehead ﬂ ap, based on
the supratrochlear artery, and the nasiolabial ﬂ ap, based
on the angular artery.

◆Preoperative Planning
Reconstruction of facial soft-tissue defects requires the
surgeon to have knowledge of wound healing physiol-
ogy, soft-tissue handling, and head and neck recon-
structive surgical techniques. Poorly designed ﬂ aps can
lead to an array of complications, ranging from minor
cosmetic deformities to functionally debilitating ab-
normalities (Fig. 5.1). The planning of surgical incisions
should adhere to the elementary principles of relaxed
skin tension lines (RSTL) and lines of maximal extensi-
bility (LME), which typically lie perpendicular to each
other. Incisions heal better when placed parallel to or
in the RSTLs, and wound tension is minimized if donor
tissue is transferred along LMEs.7,8 Additionally, wounds
placed in aesthetic unit and subunit boundaries, along

◆Brief History
The term ﬂ ap was derived from the Dutch word ﬂ appe
in the 16th century, meaning something that hung broad
and loose, secured by only one side. The ﬁ rst historical
mention of ﬂ ap surgery dates to a more remote time,
around 600 BC, when Sushruta Samhita, believed to be
part of one of the four Vedas, described what he had
learned from his mentor Dhanwantri. He eloquently de-
scribed using a cheek ﬂ ap for nasal reconstruction. The
traditional Indian technique for rhinoplasty using a ﬂ ap
from the adjoining forehead can be traced back to ap-
proximately 1440 AD.
Later surgical methods using ﬂ aps to repair defects
progressed in distinct periods. During the First and Sec-
ond World Wars, pedicled ﬂ aps were used extensively.
Subsequently the procedure of axial pattern ﬂ aps (ﬂ aps
with a named blood supply) was developed in the 1950s.
In the 1970s, the distinction between axial and random
ﬂ aps (unnamed blood supply) was ﬁ rst recognized. The
ensuing advances include the use of cutaneous, fascio-
cutaneous, muscle, musculocutaneous, and osseous tis-
sue types in ﬂ ap surgeries.

◆Vascular Anatomy
The deﬁ ning characteristic of a skin ﬂ ap is that its surviv-
al in the recipient bed is predicated upon a functioning
intravascular circulation. Historically, the design of skin
ﬂ aps was governed by a set of length-to-width ratios
(5:1 for the face due to its abundant blood supply). Lo-
cal ﬂ aps can easily be advanced, pivoted or interpolated,
thereby allowing a greater length-to-width ratio. How-
ever, in the 1970s, Daniel showed that increasing the
width of a ﬂ ap did not increase the surviving length.2,3
Rather, the amount of blood supply incorporated into a
ﬂ ap’s width dictates the ﬂ ap’s surviving length. Daniel
and Williams deﬁ ned the blood supply to the skin as be-
ing from two types of arteries: (1) musculocutaneous
arteries or (2) direct cutaneous arteries (now further
subdivided4). The skin is supplied by two vascular plex-
uses. The deep vascular plexus, or subdermal plexus, is
found at the junction of the dermis and subcutaneous
fat. The superﬁ cial vascular plexus courses in the super-
ﬁ cial aspect of the reticular dermis, giving oﬀ capillary
loops within the dermal papillae. Musculocutaneous ar-
teries are branches of segmental vessels arising from the
aorta that supply blood to muscle and continue through
the underlying muscle to the overlying dermal plexi. For
the majority of their course, musculocutaneous arteries
run perpendicular to the skin, supplying only small ar-
eas of the skin. Direct cutaneous arteries are branches of
segmental or muscular arteries that pass through fascial
septae between muscles to supply the enveloping fascia
and overlying skin. Arteries run parallel to the skin, sup-
plying a large area of the skin.5
Fig. 5.1 Patient who demonstrates multiple late sequelae of
poor defect repair choices, including alar retraction, ectropi-
on, and color mismatch between the skin graft and surround-
ing tissue.

5 Complications Involving Locoregional Flap Reconstruction of Facial Defects
31
electrocautery. Overly aggressive electrocautery, how-
ever, can increase the risk of ﬂ ap necrosis. Furthermore,
excessive thinning of the donor tissue reduces ﬂ ap vi-
ability. Minimizing wound tension will avert damage to
axial vessels and decrease the occurrence of traumatic
dissection.
The design of a facial ﬂ ap must always assimilate the
knowledge of the underlying anatomy to avoid injury
to vulnerable anatomic structures. Knowledge of the
locations of the major vessels and nerves of the face,
as well as the tissue layers in which they reside, is es-
sential when considering ﬂ ap elevation in these regions.
Invariably, small sensory nerves will be transected at
the margins of a ﬂ ap, but the mild loss of cutaneous
sensation is not usually clinically signiﬁ cant. However,
the great auricular nerve, which is located anterior and
superﬁ cial to the sternocleidomastoid muscle, can eas-
ily be injured unless one stays superﬁ cial to the fascia of
the sternocleidomastoid muscle. If the nerve is injured,
hypesthesia or paresthesia of the aﬀ ected ear may oc-
cur. The infraorbital nerve, which supplies sensation to
a large area of the midface, is also susceptible to injury,
especially in eyelid and nasolabial ﬂ ap reconstruction.
A far more serious injury can occur if the facial nerve
is injured. The temporal branch of the facial nerve is
very close to the surface as it crosses the zygomatic arch
in the temporal region.23–25 It is vulnerable to injury in
this area, especially in elderly patients with thin skin.
Transection of the temporal branch of the facial nerve
can result in the loss of forehead furrows and lead to
eyebrow ptosis. Injury to branches supplying the orbi-
cularis oculi muscle may result in diﬃ culty closing the
aﬀ ected eye. The zygomatic branch of the facial nerve is
less vulnerable as it crosses the zygoma, because it does
so in a deep plane. Transection will result in eyelid ptosis
and ectropion. Injury to the buccal branch of the facial
nerve along its course from the parotid gland to the or-
bicularis oris muscle may result in facial asymmetry, an
inability to pucker the lips, or synkinesis. The marginal
mandibular nerve is most vulnerable at the angle of the
jaw as it courses from under the parotid gland. Facial
nerve damage can result in both cosmetic deformity and
signiﬁ cant functional impairment, particularly around
the corner of the mouth. To avoid these devastating con-
sequences of facial nerve injury, ﬂ aps in these regions
should be elevated and undermined in a subcutaneous
plane to avoid disruption of the superﬁ cial musculoapo-
neurotic system (SMAS) or platysma muscle.

◆Complications and Their Management
Ischemia
Generally, the blood supply to the skin far exceeds the
skin’s nutritional demands. Blood ﬂ ow to the skin is in-
tegral for thermoregulatory function and therefore ﬂ uc-
hairlines, and in the midline of the face heal with less
perceptible scars. Wounds aligned with RSTLs are not
subjected to repetitive tension and therefore reduce the
risk of scar hypertrophy.9,10
Wound immobilization during healing will result in
better cosmetic outcomes. Two techniques commonly
employed to minimize wound tension during healing
are undermining and using deep sutures. Undermin-
ing, however, is not always the best method to relieve
excessive tension. It has been shown that beyond 4 cm,
undermining has no eﬀ ect on tension. Furthermore, an-
imal studies suggest there is a correlation between ex-
cessive skin undermining and an increased incidence of
ﬂ ap necrosis.11 Deep sutures help to relieve tension and
make wound edge eversion easier. Wound edges that are
everted at the time of closure result in better scars.
Recently, Gassner et al. have reported statistically sig-
niﬁ cant results in improved scar appearance following
use of botulinum toxin injections at the time of surgical
repair.12–15 Botulinum toxin decreases the tension on a
wound by temporarily chemodenervating the muscles
pulling on the wound. Gassner and Sherris recommend
injecting the surrounding muscles at the time of wound
closure to produce an improved scar. This theory has
been proven in a blind, placebo-controlled trial in ani-
mals and humans with forehead defects and in an open
trial with perioral wounds. Further studies using this
innovative technique are underway and are promising.
Careful attention to the aforementioned principles of
minimal wound tension is vital when the surgeon is de-
signing ﬂ aps for defects involving the nasal ala, the eye-
lids, and the vermilion border of the mouth. These areas
are extremely sensitive to unusual skin tension.16–22 In-
creased tension on the nasal ala from a poorly designed
ﬂ ap may result in alar retraction, nasal obstruction, or
both (Fig. 5.1). Poor ﬂ ap design in the eyelid region may
lead to ectropion, epiphora, or lagophthalmos, which
may further result in exposure keratitis of the cornea
with possible visual impairment. If the vermilion border
of the lip in the perioral region is subjected to excessive
tension, oral competence and speech may be compro-
mised. These defects, aside from leading to a functional
impairment, are very diﬃ cult to revise. Therefore, it is
crucial to examine these anatomic structures meticu-
lously after insetting of the ﬂ ap intraoperatively. In-
creased tension should be relieved, even if this requires
using an alternate method of closure. Consideration of
placing structural grafts under the eyelid or nasal ﬂ aps
to overcome the wound contracture is an eﬀ ective mea-
sure to prevent contracture of these important anatomic
structures.
General wound-handling principles for soft tissue
should be meticulously observed during surgery of the
face. Tissue should be handled with skin hooks and ﬁ ne
toothed forceps to minimize blunt trauma.7,8 Tissue lay-
ers need to be properly sutured to eliminate dead space.
Meticulous hemostasis should be obtained with bipolar

Complications in Facial Plastic Surgery
32
lead to impaired wound healing and an increased risk
of scar contracture.51 An area of irradiated skin that may
have marked damage to the subdermal plexus due to
obliterative endarteritis should not be used to recon-
struct a soft-tissue defect.52,53
The most common and most avoidable causes of
ischemic ﬂ ap failure in healthy nonsmoking patients
are technical errors in design and poor surgical tech-
niques, including insuﬃ cient undermining, improper
distribution of wound tension, torsion on the proxi-
mal pedicle and tension at the distal wound margin. In
general, one should avoid tension at the site of the de-
fect and more leeway should be used at the donor site
where one is encountering healthy, well-vascularized
tissue. The ability to recognize that a ﬂ ap is undergo-
ing clinically signiﬁ cant ischemia requires astute ob-
servation and an experienced surgeon. Ominous signs
include lack of bleeding at the edges, edema, venous
congestion, and a delayed capillary reﬁ ll with digital
compression. When a ﬂ ap loses perfusion for a pro-
longed period, hypoxia leads to incremental loss of
the underlying dermis as well as the epidermis. Epi-
dermolysis results from early ischemia, where the epi-
thelium desiccates and sloughs as the underlying tissue
re-epithelializes (Fig. 5.2A,B). Local wound care is suf-
ﬁ cient in treating epidermolysis, and the wound tends
to heal without signiﬁ cant scarring. However, entirely
necrotic tissue that is clinically demarcated should be
debrided to promote re-epithelialization and minimize
the potential for excessive scar formation (Fig. 5.3A,B).
Healing by secondary intention can lead to a cosmeti-
cally acceptable outcome in areas such as the temple,
forehead and concave surfaces of the face, allowing for
a less aggressive approach if the reconstruction falters
and debridement is necessary. Areas more susceptible
to wound contracture, deformity, and functional im-
pairment, such as the nasal ala, eyelid margin, or oral
commissure, should be closed using a new ﬂ ap or a skin
graft soon after debridement.54–57 Cosmetic deformities
alone can be addressed in a delayed fashion if no func-
tional impairment is inevitable.
Postoperatively, the surgeon should employ measures
to reduce edema, such as ice pack application, bed rest
with head elevation, no strenuous activity, and at times
systemic steroids to reduce the risk of ﬂ ap necrosis. Da-
vis et al. have described the application of topical oxy-
gen free radical scavengers (and combinations of these)
in random pattern skin ﬂ aps with statistically signiﬁ -
cant success in reducing the rates of ﬂ ap ischemia.58 Oral
agents have been a standard therapy although topical
agents confer the beneﬁ t of a better side eﬀ ect proﬁ le
due to decreased systemic absorption. Medicinal leech
therapy for ﬂ aps with venous congestion can result in
salvage of an ischemic ﬂ ap. Hyperbaric oxygen is an
important option in preventing full-thickness tissue
necrosis and has proven to decrease edema in healthy
tissue by inducing vasoconstriction and stimulating
tuates widely as demand varies. This oversupply allows
for random ﬂ ap viability. The face, in particular, has a
rich blood supply from the subdermal plexus. Therefore,
local random ﬂ aps on the face survive with fewer com-
plications due to vascular compromise than local ﬂ aps
in other regions of the body. As previously mentioned,
axial ﬂ aps in the face are based on the superﬁ cial tem-
poral, supraorbital, supratrochlear, transverse facial,
and facial angular arteries, which ensure a robust vascu-
lar supply, so axial ﬂ aps can therefore be designed with
a longer ﬂ ap length than random ﬂ aps.26–32
Probably the most common complication of locore-
gional ﬂ ap reconstruction is postoperative ischemia.
Ischemia, by deﬁ nition, is a compromise of the vascu-
lar supply that is inadequate to provide suﬃ cient tissue
oxygenation and results in lessened ﬂ ap viability. Flap
ischemia may be caused by multiple factors, including
poor ﬂ ap design, infection, venous congestion, excess
tension, or underlying vascular disorders.33,34 Ischemia
may lead to tissue compromise due to hypoxia, com-
plicated by dehiscence, infection, free radical produc-
tion, and ultimately ﬂ ap necrosis.35–39 Smoking greatly
increases the risk of ﬂ ap ischemia. Thus, patients are
encouraged to stop smoking two weeks before and two
weeks after ﬂ ap surgery.
Active bleeding at a ﬂ ap’s distal margin during sur-
gery is typically a good sign of tissue perfusion.40–42
However, perfusion cannot be correlated with adequate
tissue oxygenation.43 Tissue requirements and hemoglo-
bin saturation change in response to trauma, the pres-
ence of free radicals, acidosis, and thromboxane A2.44–46
In the ﬁ rst 48 hours after surgery, there is a surge in
local catecholamine release and vasoconstricting me-
diators in the inﬂ ammatory cascade, resulting in local
vasoconstriction and edema. These factors all contrib-
ute to ischemia or direct injury to the ﬂ ap. In addition,
temperature, wound tension, bleeding, and atheroscle-
rosis all aﬀ ect oxygen transport within the tissue. Flaps
that are shorter, with an abundant blood supply, usually
do well. In the face, there are multiple large subcutane-
ous vessels allowing for longer ﬂ aps, such that widening
a ﬂ ap in proportion to the length is not necessary. The
capillary perfusion pressure at the distal tip is critical,
driven by the subcutaneous vessels in random facial
ﬂ aps.47–49 A delay procedure has been shown to increase
ﬂ ap vascularity and, as a result, ﬂ ap length and viabil-
ity. Baker et al. have described increased ﬂ ap survival
lengths through use of tissue expanders even greater
than the increase in survival length seen with the delay
technique.50
Previously irradiated skin may have a compromised
blood supply, with increased fragility and propensity
for injury. Skin irritation and breakdown are not un-
common following radiation. The damage in pattern of
blood ﬂ ow and soft-tissue architecture due to radiation
radically changes the prospects for ﬂ ap survival. Scar-
ring from prior radiation and increased ﬁ brous tissue

5 Complications Involving Locoregional Flap Reconstruction of Facial Defects
33
contaminated wounds and should always be used in
contaminated wounds (trauma, infected cyst excision).
Choice of regimen is guided by knowledge of the probable
contaminating ﬂ ora associated with the operative site.60
The activity of the chosen agents, therefore, should en-
compass the pathogens likely to contaminate the wound
and the agents should be administered in a dose suﬃ -
cient to achieve optimal tissue concentration prior to the
initial incision.61 Patients at high risk for wound infection
should be treated prophylactically to cover Staphylococ-
cus aureus (most common etiology of skin wound infec-
tions) and Streptococcus viridans (a common pathogen of
oral ﬂ ora). Most commonly, a cephalosporin or penicillin
may be used. Amoxicillin with clavulanate or clindamy-
capillary ingrowth as well as decreasing tissue hypoxia.
Hyperbaric oxygen itself has associated risks, such as
barotrauma, pneumothorax, increased risk of cataract
formation, and seizures.
Infection
Postoperative wound infections, manifest by local ery-
thema, edema, tenderness and drainage, occur most
frequently in contaminated wounds (up to 20%). Clean
wounds have a signiﬁ cantly lower incidence of infec-
tion (1–4%), and clean-contaminated wounds carry a
8–10% risk of postoperative infection.59 Prophylaxis is
not indicated for clean wounds but may be used in clean-
Fig. 5.2 (A) Patient one week after dog bite injury
with nearly complete earlobe avulsion. Note the
epidermolysis (dark purple) in the photograph.
(B) One month later, the wound has healed with-
out signiﬁ cant tissue loss.
Fig. 5.3 (A) Complete tissue necrosis (black) after
reattachment of a full-thickness ear wound.
(B) The necrotic tissue was debrided and the
raw surfaces were covered with a local ﬂ ap until
delayed, deﬁ nitive reconstruction.
A
B
A
B

Complications in Facial Plastic Surgery
34
ty. The surgeon should use the smallest adequate suture
and needle. It has been shown in a mouse model that
monoﬁ lament sutures are less susceptible to bacterial
adherence than braided sutures.
If an infection arises, patients are placed on oral an-
tibiotics. Topical antibiotics are applied to the aﬀ ected
area three to four times a day. If the infection fails to
respond to conservative management, ﬂ ap viability is
threatened by the release of proteolytic enzymes that
cause local cell death and vascular thrombosis. Ischemia
is exacerbated by physical stretch of the wound second-
ary to abscess formation as well as restricting blood ﬂ ow
(Fig. 5.4). Abscesses should be drained, expeditiously
cultured, and thoroughly irrigated. Drainage is accom-
plished by removing some of the distal ﬂ ap sutures,
compressing and exploring the wound. In addition to
draining the abscess, relieving the tension on the dis-
tal ﬂ ap will reduce the probability of ﬂ ap necrosis. The
wound can then be packed with gauze and a Penrose
drain or wick can be placed until drainage ceases.
Bleeding
Bleeding may be precipitated by uncontrolled hyper-
tension, an occult drug, or congenital coagulopathy
contributing to diﬃ cult hemostasis.64,65 Bleeding dur-
ing surgery should be meticulously controlled using
electrocautery. It has been shown that bipolar cautery
causes less tissue damage due to less thermal energy re-
lease than seen with monopolar cautery. Excessive cau-
terization can lead to alopecia in hair-bearing areas and
increased scar formation. It will also cause the margins
of the ﬂ ap to be more conspicuous and less attractive
cosmetically.
If a wound has persistent oozing at the time of sur-
gery, ﬁ brin glue can be sprayed in a thin coat, and the
ﬂ ap held in place over the wound for a few minutes. The
ﬁ brin glue promotes clotting and will incite ﬂ ap adher-
ence to the underlying tissue bed. Pressure dressings
and drains (rubber band or Penrose) can help minimize
the risks of hematoma or seroma formation, but care
must be taken not to cause ischemia with their place-
ment. A closed suction drain may be necessary in large
defects. A hematoma can cause increased tension on the
wound closure, potentially resulting in ischemia, dehis-
cence, infection and circulatory compromise. Hemato-
mas should be expeditiously evacuated by either needle
aspiration or by creating an opening at the distal wound
margin and performing manual compression and la-
vage. Irrigation should be continued until all residual
clots are removed. Packing the wound or closing with a
few interrupted sutures at the distal margin should be
done only after adequate hemostasis has been achieved
and should not apply excess tension at the wound edges.
Medications associated with increased bleeding times
including aspirin, NSAIDs, and herbal remedies (vitamin
E, garlic, feverfew) and should be discontinued 7–10
cin (for enhanced anaerobic coverage) is also widely used.
Pseudomonas aeruginosa must be covered when exposed
cartilage or bone near the ear canal is involved. A dated
ﬂ uoroquinolone, Ciproﬂ oxacin, is still often the drug of
choice in these circumstances.62,63
Strict adherence to aseptic surgical technique is criti-
cal to prevent infection and to avoid compromising lo-
cal host immune defenses by interfering with blood
ﬂ ow or causing local inﬂ ammation. A well-approximat-
ed wound, with adequate hemostasis and a minimal
amount of devitalized tissue, is more resistant to infec-
tion. Excessive manipulation of wound edges, poor tis-
sue handling, and inappropriate suture placement can
impair dermal capillary blood ﬂ ow, leading to ischemia
and an increased risk of infection. Other factors associat-
ed with an increased risk of infection include prolonged
procedures lasting more than 2 hours, complicated
operative sites (ulcerated tumor, irradiated lesion, in-
ﬂ amed cyst, reexcision of recent biopsy site), and the
presence of drains. Patient proﬁ les, including advanced
age, presence of diabetes mellitus, immunocompromise,
obesity, or substance abuse, also predispose to infection
(Fig. 5.4). Areas around the nose, mouth, and ears have a
relatively high bacterial count and are similarly prone to
infection. Suture materials are foreign bodies that incite
a local immune response, thereby increasing infectious
risk due to compromising local infection-ﬁ ghting abili-
Fig. 5.4 Infected cartilage grafts with ﬁ stula formation and
tissue necrosis in a diabetic patient who underwent forehead
ﬂ ap nasal reconstruction a month prior to the infection. The
wound was treated with debridement and healed adequately
after intravenous antibiotics and wound care.

5 Complications Involving Locoregional Flap Reconstruction of Facial Defects
35
the formation of HTS and keloids is poorly understood,
the common belief is that trauma is the precipitat-
ing event. Furthermore, mechanical tension and strain
on wound edges is one of the most important factors
linked to the formation of HTS and keloids.66,67 This has
been conﬁ rmed by the fact that wounds at right angles
in relaxed skin tension lines develop HTS and keloids at
an increased rate. It is therefore crucial to design ﬂ aps
for facial defects in a way that minimizes tension and
positions incisions in RSTLs parallel or as near parallel
to them as possible. The majority of these abnormalities
are asymptomatic, although pruritus is the most com-
mon associated symptom and is hypothesized to be due
to increased mast cells and increased histamine levels.
As mentioned previously, the best way to avoid com-
plications is meticulous preoperative planning and
sound surgical technique. In known keloid-formers, the
incisions should be as short as possible, and the wounds
closed with monoﬁ lament deep sutures, using either
running intracuticular suturing technique or tissue
glue. However, even under the best of circumstances,
HTS and keloids still occur. Surgical revision generally
yields a positive outcome when performed after the ini-
tial wound healing phase is completed, but it does not
guarantee that there will not be a recurrence. Follow-
ing revision, is it important to use pressure and range
of motion exercises to prevent contractures from re-
curring. Management of HTS and keloids has included
intralesional steroid injections, surgical removal, sili-
cone sheeting, silicone gel, and nonsilicone occlusive
dressings. The 585-nm pulsed dye laser has also shown
variable results in reducing symptoms and improving
appearance.68 Other treatments that have been used are
topical retinoids, cryosurgery, interferon α2b, and low-
dose ionizing radiation.
days prior to surgery and for at least 7 days postopera-
tively. As a precautionary measure, patients should be
provided preoperatively with a list of contraindicated
medications and detailed wound care instructions.
Dehiscence
Dehiscence results when a wound fails to heal in ap-
position. In the ﬁ rst week after surgery, the healing
wound has only 3–5% of its original tensile strength.
Although re-epithelialization occurs rapidly (within
24–48 hours), subsequent collagen deposition is de-
layed until approximately day ﬁ ve. Collagen remodeling
increases the tensile strength of the wound over sev-
eral months. Wound dehiscence can be due to systemic
factors, such as age older than 65, hypoalbuminemia,
obesity, malignancy, hypertension, Cushing’s disease,
thyroid disease, liver disease, history of radiation ther-
apy to the site, and congestive heart failure (CHF). Ad-
ditionally, the use of tobacco, anticoagulants, systemic
corticosteroids, and cytotoxic chemotherapeutics have
an adverse eﬀ ect on wound healing, thereby predis-
posing a patient to wound dehiscence. Prevention of
wound dehiscence is best achieved by good surgical
technique. Buried absorbable sutures should provide
adequate tensile strength and last long enough to pre-
vent dehiscence. In choosing suture material, the prac-
titioner should take into account the tensile strength
retention properties of the material used. Anti-tension
taping (e.g., Steri-strips) and a bulky dressing provide
wound immobilization and some protection for the
area. If wound dehiscence occurs due to premature su-
ture removal or trauma without evidence of infection,
the wound can be resutured immediately after debrid-
ing devitalized tissue. In cases of delayed hematoma or
infection, the wound is best treated by allowing it to
heal by secondary intention. Scar revision can then be
planned after adequate healing has occurred, usually
no sooner than eight weeks.
Scar Contracture, Hypertrophic Scars, and Keloids
Hypertrophic scars (HTS) and keloids represent a
pathologic response to tissue injury. By deﬁ nition, a hy-
pertrophic scar is a ﬁ brous tissue outgrowth with ex-
cessive scarring that remains within the conﬁ nes of the
wound.66,67 A keloid is characterized by its ability to ex-
tend outside the boundaries of the original lesion. Scar
contracture results when a contractile wound-healing
process occurs in a scar that has already re-epithelial-
ized and satisfactorily healed. Each of these processes
can cause cosmetic disﬁ gurement and functional dis-
ability (Fig. 5.5). Management of these physiologically
distinct processes diﬀ ers because of their diﬀ erent
patterns of evolution. Therefore, the surgeon must dif-
ferentiate among these categories, as they require dif-
ferent treatments. Although the exact mechanism for
Fig. 5.5 Hypertrophic scar at the earlobe cheek junction.